SPRING 2008
1
ii
i ALUMNI BULLETI
CHORDS OF
DISQUIET
Did psychiatric illness help
or hinder the creativity
of some of history's most
celebrated composers?
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H
Ida Henrietta Hyde was a woman
of firsts: first woman researcher at
Harvard Medical School, in its
Department of Physiology; first
female graduate of Germany's
University of Heidelberg; and first
woman to be elected to the Ameri-
can Physiological Society. Although
she was accepted to the Johns
Hopkins School of Medicine, Hyde
chose to research animals' physio-
logical systems instead. To aid in this
effort, in the 1 930s she invented the
microelectrode, a device credited with
revolutionizing neurophysiology.
" ^
SPRING 2008 • VOLUME 81, NUMBER 2
r.ONT
DEPARTMENTS
Letters 3
Pulse 6
Musical notations, from the Longwood
Symphony Orchestra's performances, to
the Music & Medicine section of the
Bulletin's new website, to the choruses of
the School's 101st Second Year Show
President's Report 11
hy William W. Chin
Sparks of Inspiration 12
Donald Berwick seeks to remedy health
care's problems through redesign, not
reprimand, hy Ann Marie Menting
Bookshelf 14
Bookmark 15
A review by Elissa Ely of 8 Weeks
to Optimum Health
Benchmarks 16
Research on ensuring transplantation
success, spurring new bone to form, and
determining when brain death occurs
Class Notes 54
InMemoriam 57
M.]udahFolkman
InMemoriam 58
Oglesby Paul
InMemoriam 59
Benedict F. Massell
Obituaries 60
Endnotes 64
Remember the old joke about how
God thinks he's a surgeon as he strides
around Heaven in a long white coat?
hy Anthony S. Patton
N
yf*
JVER STORY I
Chords of Disquiet 20
Did psychiatric illness help
or hinder the creativity
of some of history's most
celebrated composers?
by RICHARD KOGAN
FEATURES
This Side of Paradise 28
Rampant violence in his barrio leads a boy to risk his life to immigrate
to the United States — and inspires him to become a healer.
fc)' HAROLD FERNANDEZ
Small Craft Advisory 36
Medicine needs to steer a course that balances inspiration and science
to achieve a health care system that works for all.
by DANIEL D. FEDERMAN
The Obstacle Source 42
The most critical roadblock to delivering care in the developing world
is not money, but an implementation bottleneck.
b_yJIM YONG KIM
Inside Out 48
Early investigations of x-ray by two Harvard-educated physicians
revealed the technology's benefits — and dangers.
by JOHN W. GITTINGER, JR.
Cover photo of George Gershwin: Edward Steichen/Condc Nast Archive/Corhis
HarvarH Merlip^l
ALUMNI BULLETIN
EDITOR-IN-CHIEF
William Ira Bennett '68
In This Issue
XPERTISE IS A RECIPE FOR EXTINCTION. SPECIALIZATION AND MASTERY ARE
advantages only when an ecological niche remains unchanged. Who
can know whether the dinosaurs looked out on the world they were
losing with placid or terrified eyes? What we do know is that most members of
the species latromcgalos amcricanus, also known as American physicians, are aware
that something resembhng disaster is impending, and many of them are alarmed,
but also seemingly immobilized, by the prospect.
U.S. medicine has developed matchless capacity but suffers from severely
unpaired delivery. Endowed with the most expensive health care system in the
world, the United States achieves a relatively low yield in the health of its popu-
lation as compared with those of other developed countries. We all know this is
the case. Why are we not ashamed? Why are we not changing it?
In the first half of the past century, "organized medicine" — also known as the
American Medical Association — was successful in helping to block a national
health care plan, calling it socialized medicine. In 1939, Morris Fishbetn, for
25 years editor of the AMAs journal, called the plan, "... a beginning invasion
by the state into the personal life of the individual ... a definite step toward
either communism or totalitarianism."
However misleading, this theme has ever since been a mainstay of opposition
to a national health care program. It resurfaced in Ronald Reagan's 1961 venture
into pohtics on behalf of the AMA, when he warned that if Medicare legislation
were to pass, "one of these days you and I are going to spend our sunset years
teUing our children and our children's children what it once was like in America
when men were free." Three decades later, the insurance industry successfully
played the same notes in its "Harry and Louise" advertisements, indefinitely
setting back health care reform.
Now it is 2008, and patients have learned how severely private insurance can
restrict their freedom to choose a physician; physicians have learned how thor-
oughly their therapeutic choices can be limited; and both have experienced con-
siderable intrusion into the privacy of their relationship. The AMA continues to
favor private insurance, but now with government subsidies. Other physician
groups argue that nothing short of a universal, national plan makes economic
or medical sense. And many in the trenches are disengaged. In this issue of the
Bulletin, Daniel Federman '53 calls on physicians to recognize that medicine
cannot continue on its old course and to get serious about plotting a new one.
^,U^
Cm[ IAa
Paula Brewer Byron
ASSOCIATE EDITOR
Ann Marie Menting
ASSISTANT EDITOR
Jessica Cerretani
EDITORIAL INTERN
Kathleen Preston
BOOK REVIEW EDITOR
ElissaEly'88
EDITORIAL BOARD
JudyAnn Bigby '78
Rafael Campo '92
Elissa Ely '88
Daniel D. Federman '53
Timothy G. Ferris '92
Alice Flaherty '94
Atul Gawande '94
Robert M. Goldwyn '56
Perri Klass '86
Victoria McEvoy '75
James J. O'Connell '82
Nancy E. Oriol '79
Anthony S. Patton '58
Mitchell T. Rabkin '55
Jason Sanders '08
Eleanor Shore '55
DESIGN DIRECTOR
Laura McFadden
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
ASSOCIATION OFFICERS
Wilham W. Chin '72, president
Steven E. Weinberger '73, president-elect 1
JudyAnn Bigby '78, president-elect 2
Ken OSit '81, vice president
Rodney J. Taylor '95, secretary
Douglas G. KeUing '72, treasurer
COUNCILLORS
Rosa M. Crum '85
Laurie Ghmcher '76
Edward D. Harris, Jr. '62
Jim Yong Kim '86
Triste N. Lieteau '98
Christopher J. O'Donnell '87
Michael Rosenblatt '73
Rachel G, Rosovsky '00
John D. Stoeckle '47
DIRECTOR OF ALUMNI RELATIONS
George E. Thibault '69
EXECUTIVE DIRECTOR OF
ALUMNI RELATIONS
Mary Moran Perry
REPRESENTATIVES TO THE
HARVARD ALUMNI ASSOCIATION
Joseph K. Hurd, Jr. '64
John D. Stoeckle '47
The Harvard Medical Alumni Bulletm is
published three times a year at
25 Shattuck Street, Boston, MA 02115.
o Harvard Medical Alumni Association
Phone: 617-384-8900 • Fax: 617-384-8901
Email: buUetin@hms.harvard.edu
Web: http://alumnibulletin.med.harvard.edu
Third class postage paid at Boston,
Massachusetts. Postmaster, send form 3579
to 25 Shattuck Street, Boston, MA 02115
ISSN 0191-7757 • Printed in the U.S.A.
SECOND OPINIONS FROM OUR READERS |
T 17' nn nn yp "D C^
REBELS WITHOUT A PAUSE
Plaudits for your excellent Spring/
Summer 2007 issue on medical edu-
cation. I especially enjoyed the
"Endnotes" piece on the curriculum
rebellion of 1966, which was trig-
gered by students' concerns that
they were rapidly going brain-dead
under the impact of the old preclini-
cal years. Many members of the Class
of 1956 felt similarly — how could
the World of Ideas have disappeared
so suddenly into a maelstrom of
unrelated facts being crammed into
one's brain like the Chinese method
of preparing Peking duck by force-
feeding young poultry with a pump and plastic tube?
Three of us second-year students began meeting every Friday to
drink wine and exchange ideas on how to avoid having our brains
become shrunken walnuts. Each of us decided not to share with the
others his own preventive measure for this fascinating neurological
problem. So imagine our surprise when, in the spring, each of us
announced that he was taking a year off from medical school to con-
sume more nutritional brain foods. Lon Curtis '56 won a fellowship to
Europe and the Middle East to delve into history. BUI Ruddick took a
Woodrow WUson Fellowship to study philosophy at Oxford and
remained there for his doctorate, never returning to HMS. I won a
Frederick Sheldon Traveling Fellowship to the South Pacific and Africa
and have kept international health as a hobby ever since.
Our experience exemplifies how some classes earlier than the 1960s
and 1970s dealt with the problem of the stifling, overly factual, idea-
impoverished, mind-desiccating first two years of the old curriculum.
PAUL H. ALTROCCHI '56
KANEOHE, HAWAII
Decoder Ring
I enjoyed reading "Endnotes" in the
Bulletin's special report on medical edu-
cation. At the end of the piece, the author
noted that the course syllabus the facul-
ty provided was called a "camel" because
it reflected "an organism designed by a
committee." The definition of the
"camel" I was given when I attended
HMS, though, was "a horse designed by
a committee." In my humble opinion,
that is a more insightful — and pleasingly
amusing — description of the beast.
The piece's recounting of the cur-
riculum rebellion of 1966 reminded me
of what we might call the "grading boy-
cott of 1973," which members of the
Class of 1977 perpetrated. As I remem-
ber it, we had been told during the
application process and before our
matriculation in 1973 that all grading
would be on a pass/fail basis. After we
matriculated, though, we learned that
the grading system would consist of
more levels than simply pass or fail.
Having come of age during the rebel-
lious and anti- establishment era of the
late 1960s and early 1970s, we found
this turn of events unacceptable.
Discussion with the administration
about this issue proved less than fruit-
ful. If I recall correctly, Dean Robert
Ebert, in a meeting with the entire class
in one of the amphitheaters, reminded
us that out there in the real world was a
plethora of potential students who
would gladly fill our slots, a notion that
did not sit favorably with us. So we
decided to stage a boycott.
During the physiology final exam,
which was the first test that would be
graded using the disputed new system,
we would substitute numbers in place
of names on our papers, with the decod-
ing key being held by a neutral faculty
member or administrator. The idea was
that any student receiving a failing
grade on the exam would be honor
bound to reveal his or her identity to the
course's faculty. Those who received a
passing grade were under no such oblig-
ation, and the faculty would have to
assume we had all passed. The resulting
compromise was a grading system that
had more levels than simply pass or
fail but fewer levels than the School
had planned.
Our boycott did have one unintended
and regrettable consequence: Clifford
Barger '43A, the head of the physiology
course, mistakenly beheved the boycott
resulted from discontent with him and
the physiology course. We reassured him
that the purpose of this action was solely
to remedy the situation with the School's
grading system.
This recounting is based on my memo-
ry of events that occurred decades ago, so
I encourage those of you with better
memories or more knowledge to make
any corrections or additions.
MASSAD GREGORY JOSEPH 'JJ
SOUTH PASADENA, CALIFORNIA
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
:^ T.FTTFRS
I SECOND OPINIONS FROM OUR READERS
Scrabble Game
The "Endnotes" article in the Spring/
Summer 2007 issue of the Bulletin about the
lecture ser^ice brought back memories.
In September 1950, a number of us
were sitting in Dave Poskanzer's room
in Vanderbilt Hall — I believe Frank
Austen '54 was there — discussing the
absurdity of every student frantically
scribbling notes. We decided to ask for
three volunteers in each course to take
notes and then combine them into
coherent sentences. Fortunately we
found someone in the dean's office to
type them up and make mimeographed
copies for the entire class.
The plan worked surprisingly well —
except Frank consistently did better on
exams than I did!
JIM UPSON '54
ORCHARD PARK,
NEW YORK
Simply the Best
when Judah Folkman '57 died suddenly
on January 14, the Harvard Medical School
community suffered a devastating loss.
Although he was best known for his
INNOCENCE OF THE DAMNED
I found the article that Anthony Patton '58 wrote on Augustus Holyoke
of Salem, Massachusetts, in the Spring/Summer 2007 issue of great
mterest, as my ancestors came from Dam ers which was part of Salem.
When I was small,
my parents took me
to Danvers to cele-
brate an anniversary
of Rebecca Nurse,
who was declared
a witch and hanged
in Salem in 1692.
Those in attendance
at the anniversary
celebration were all
Nurse's direct
descendants. My
cousin, a local histo-
rian in Danvers,
ended up writing a
book about Nurse
and her persecution.
One time my
father, who was a doctor in Hanover, New Hampshire, went to a meet-
ing on diabetes with Elliott Joslin, a member of the Class of 1895 and the
founder of the Joslin Diabetes Center in Boston. My father took me along
on the trip, but I had to sit out in the car. I later asked him what they
had discussed, and he replied that they had talked about ancestors.
ROWLAND FRENCH '43B
EASTPORT, MAINE
scientific discoveries, Judah actually
centered his work on patients. Kind-
ness, humanity, and curiosity were at
the core of his life.
I first got to know Judah when he was
a fourth-year HMS student working in a
dusty corridor of what was then Peter
Bent Brigham Hospital. He was doggedly
trying to transplant kidneys into rats;
later he and I often chuckled over that
memory, as his lack of proper instrumen-
tation made it an exercise in futihty
After graduating magna cum laude
and completing a surgical residency at
Massachusetts General Hospital, Judah
worked with Bill McDermott '42 at
Boston City Hospital. Later, when he
started his own practice at Children's
Hospital, Judah instituted a pohcy of
giving his home phone number to
patients. He also carried a notebook of
their numbers when he traveled.
As a teacher Judah was magnetic, and
his lectures were always crowded. When
necessary he could be firm. He once
warned medical students, "You have
chosen a service profession. Get used
to it. If you don't like long hours, coping
with patients, and being on call, then do
something else. You could be a banker."
My golden years with Judah were at
Children's Hospital when he was sur-
geon-in-chief. Driven by his multiple
responsibilities, he practically lived at
the hospital. At all hours he was consid-
erate to senior staff, residents, anes-
thetists, nurses, and orderlies alike.
Nothing could distract him from his
goal of giving his best to patients.
During the 1970s, I discussed one of
Judah's papers at the American Surgical
Association meeting in Florida. His
report on angiogenesis had been typi-
cally sparkling. Yet I focused my
remarks on his other, equally impres-
sive qualities.
Judah's outstanding leadership in
biological surgical research is known
worldwide, I told the association mem-
bers. But when a person develops a
highly visible profile in one phase of his
professional life, there is a tendency to
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
PARADE OF ROSES: Lois Hunter, a 1956 graduate of the Children's Hospital School of Nursing, is third ro>v from bottom, sixth from left.
minimize his other talents. Only those
of us working with him daily realize his
solid clinical judgment and skills and
the extraordinary effect his inquisitive
mind has on the daily rounds of all the
clinical services of Children's Hospital.
Whether his studies lead to the control
of cancer or the understanding of arterio-
venous malformations, his influence on
the thinking and teaching of staff, resi-
dents, and students is enormous. He is
an excellent clinical surgeon doing out-
standing research.
Afterward, Judah thanked me for my
remarks, and I was especially pleased
to learn that his mother had been in
the audience.
It is most satisfying for me to share
Judah's attributes with his many griev-
ing friends, colleagues, patients, and
fellow graduates.
JOSEPH E. MURRAY '43B
WELLESLEY HILLS, MASSACHUSETTS
A Touch of Honey
o My wife and I appreciated the photo of
£ the Children's Hospital nurse and
patient in the Autumn 2006 issue of the
Bulletin. My experience was similar to
that of Henry Work 37, who noted that
he had been fortunate to marry a Chil-
dren's Hospital nurse. I met Lois Anne
Hunter, CMldreris '56, while at Harvard
College, and we are celebrating our
fiftieth wedding anniversary this year.
While at HMS, I was always
impressed with Children's Hospital
nurses, and I knew my patients would
receive superb care when one of those
graduates was on the ward. Shortly
after Lois's graduation, Drs. Robert
Gross and Robert Smith, who had just
begun to perform open-heart pediatric
surgeries, asked Lois to take a lead role
in establishing the country's first pedi-
atric recovery room. She was successful
in this endeavor and was delighted,
upon returning several years later, to
find that the staff was still using the
procedures she had developed.
Once, while I was working as a tech-
nician on a research project with Dr. Dav
Cook, I had to go to the recovery room
to ask my wife whether I could borrow
a laryngoscope since the batteries in the
one Cook was using had died. She
emphatically told me that I couldn't
have it because they might need it for an
emergency. My "But, honey" had no
effect except to cause smothered laugh-
ter among the other recovery room
nurses. When I returned to confess my
failed mission to Cook, the entire group
burst out laughing, and I learned that
she had refused them as well.
The Children's Hospital Alumni Asso-
ciation had its final meeting in Boston
in 2006, the fiftieth anniversary of my
wife's graduation, and many of her
classmates attended. I recognize that
I am "chronologically challenged," but I
regret the evolution from the nurse as a
supportive team member to a "nurse
manager" role.
ROYCE MOSER, JR. '6l
SALT LAKE CITY, UTAH
The Bulletin welcomes letters to the editor.
Please send letters by mail (Harvard Medical
Alumni Bulletin, 25 Shattuck Street, Boston,
Massachusetts 02115); fax (6J7- 384-8901); or
email (hulktin@hms.harvard.edu). Letters may
be edited for length or clarity.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
I
pttt.se
MAKING THE ROUNDS AT HMS
All the Right Notes
S
CALPELS AND STETHOSCOPES AREN'T
the only instruments some
physicians skillfully wield.
When they aren't studying,
conducting research, or caring for
patients, the forty-odd HMS students
and alumni who help compose the
Longwood Symphony Orchestra (LSO)
still have their hands full — ^with violins,
cellos, and flutes.
The orchestra's roots within Harvard
Medical School run deep. Established in
1982, the orchestra was the brainchild of
musically inclined HMS students and
professors who wanted to play together.
Today, the LSO has 120 musicians, three-
quarters of whom are physicians and
other health care professionals from
area hospitals and medical schools. Two
HMS students — Sandy Mong '08 and
Sherman Jia '11, both violinists — were
appointed co- concert masters for the
orchestra's 2007-2008 season.
The connection between music and
medicine is an instinctual one for many
physicians, says the LSO's president,
Lisa Wong, an HMS clinical instructor
in pediatrics. "Medicine is based in sci-
ence, but with practice,
you make it an art," she
explains. "Music is very
similar. Once you per-
fect the technique, you
add the artistry." And
like medicine, practic-
ing music requires dedi-
cation. "Residents often
trade their call sched-
ules so they can perform
with us," says Wong,
who admits that pagers
do sound during prac-
tice, but quips that
"they go off in tune."
That dedication isn't
limited to the stage. In
1991, the LSO cemented
its commitment to com-
munity service by intro-
ducing its Healing Art of
Music Program, an ini-
tiative to raise funds and
awareness for various
medical nonprofit orga-
nizations. "Rather than
simply donating money
to these groups, we ask
them to purchase blocks
of tickets and then work
together to create a unique fundraising
event," says Wong. This blend of creativi-
ty and collaboration has paid off: Since its
inception, the program has helped raise
more than $800,000 for nearly 30 organi-
zations, including the Dimock Communi-
ty Health Center, Partners In Health, and
the Shriners Burn Hospital Boston. The
soundtrack for these events is equally
varied. LSO conductor Jonathan McPhee,
who also serves as music director for the
Boston Ballet, enjoys introducing Boston
audiences to pieces they may not have
heard recently — or ever — such as the
twentieth- century Czech composer Leos
Janaceks Glagolitk Mass.
The program recently expanded its
direction in honor of the orchestra's 25th
anniversary by offering a series of free
daytime symposia on pubhc health issues
such as AIDS, global health, and women's
rights, with each symposium capped by
an evening benefit concert by the LSO.
The orchestra capped its latest season
with participation in a London sympo-
sium on cancer care, including lectures —
both of the LSO's trumpeters are oncolo-
gists — and a concert.
The 2008-2009 season, which will
focus on the role of music and the mind
in healing, will feature a concert cele-
brating the 60th anniversary of Albert
Schweitzer's visit to the United States.
In planning the program, Wong, a vio-
linist, has considered the powerful
effect of Schweitzer's reverence for life
on the music and minds of her fellow
symphonists. "The way we play changes
when we know we're performing for
something beyond ourselves," she says.
"We don't obsess over hitting every
note perfectly; we're thinking about
what we're playing /ok"
For more information, visit www.
longwoodsymphony.org. ■
SYMPHONY HAUL: The Boston medical community has yielded a
trove of musical talents, including violinist Lisa Wong, president of the
Longwood Symphony Orchestra, and violist Nicholas Tawa, Jr., '81.
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
Live and Learn
E!
46'YEAR'OLD WOMAN ARRIVES
at your office complaining of
painful, stiff joints that are
visibly swollen. She's over-
weight and fatigued but doesn't exhibit
a rash or fever. After taking her history
and performing a physical examination,
you've narrowed the diagnostic possi-
bilities to osteoarthritis, rheumatoid
arthritis, gout, or fibromyalgia. Which
is she most likely to have?
Medical mysteries Kke this form the
basis of CME Online, the distance learn-
ing program of Harvard Medical School's
Department of Continuing Education.
And now, thanks to the initiative and
efforts of the Harvard Medical Alumni
Council, such opportunities for lifelong
learning are not only easily accessible for
HMS graduates, but more affordable as
well. In agreement with the Council,
the department is offering alumni sig-
nificant discounts on its online courses,
its live courses, and its primary care
medicine programs.
For 40 years, the department has
offered quality continuing medical
education programs that have earned
international renown. More than 60,000
clinicians participate in the depart-
ment's live courses, conferences, or
online programs each year. In 2003, the
department launched CME Online,
which allows health professionals to
learn from peers around the globe with-
out ever leaving their desks. In the five
years since it was established, CME
Online has enrolled 7,000 people from at
least 110 countries.
With the goal of providing health
professionals with tools to help them
optimize patient care, the department's
programs present the most up-to-date
medical information and strategies for
physicians and other health profession-
als. The courses pertain to all medical
disciplines and cover a range of topics
relevant to the science, practice, and
teaching of medicine.
Special Offers to HMS Alumni
THANKS TO THE HARVARD MEDICAL ALUMNI COUNCIL/ HMS GRADUATES CAN NOW
enjoy special discounts on Department of Continuing Education programs, including:
Online Courses. The department offers several dozen online courses through CME
Online, with many others under development. HMS alumni are eligible for a 50-percent
discount on these courses.
Live Courses. HMS alumni receive a 1 5-percent tuition discount on live courses. To be
eligible, they must register at least 60 days before the start of the course.
Primar/ Core Medicine Programs. The department has waived registration fees
for HMS alumni enrolling in any of its seven Current
Clinical Issues in Primary Care Medicine programs
throughout the United States and in Mexico. Alumni
are also welcome to make themselves at home in the
HMS speakers' lounge, where they can meet with
keynote speakers and other colleagues over break-
fast and lunch and throughout the sessions. ■
To learn more about
these offers, visit http://
alumnibulletin.med.
harvard.edu/resources/
benefits/cme.php
CME Online offers a variety of
approaches to learning. The computer-
based program includes interactive
quizzes, laboratory results, pho-
tographs, and other related images that
bring clinical cases to life and make
learning enjoyable. Clinicians can
choose from a range of topics, such as
"Management of Atrial Fibrillation,"
"Endocrine Emergencies," and "Clini-
cal Challenges in Toxicology."
Each module contains a compelling
case study that presents a patient's
symptoms — in one case, a 58-year-old
woman v^th a history of breast cancer
experiences back pain; in another, a 23-
year-old man exhibits stomach distress,
depression, and fatigue — and questions
users on the appropriate tests, diag-
noses, and treatments. In addition to
offering an interactive question- and-
answer format, the program allows
readers to compare their answers with
those of their peers and to email the
module's author for more information.
And the "save as you go" function makes
it easy for busy clinicians to pursue
credits at their own pace.
For more information about the
Department of Continuing Education,
visit its website at http://cmeonhne.med.
harvard.edu. ■
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
pttt.se
MAKING THE ROUNDS AT HMS
Easing the Debt Burden
FFORDING A TOP-QUALITY MEDICAL EDUCATION IS
about to get easier for many HMS students. Dean
Jeffrey Flier recently announced a new financial
aid initiative aimed at reducing debt for medical
students and their families. The School has approved a signifi-
cant decrease in the financial contribution expected from fam-
ilies earning $120,000 or less annually — a reduction estimated
to save each family approximately $50,000 throughout the tra-
ditional four-year program. This policy revision wUl affect
about one-third of HMS students.
Formed in part by the School's Strategic Advisory Group
on Education, the initiative comes as levels of student debt
reach new heights. With rates of indebtedness rising more
quickly than starting salaries in many areas of the profession,
medical students often feel pressured to choose more lucra-
tive specialties. Minimizing this pressure, says
Flier, will help students make career •••***
decisions based on their interests and abilities rather than on
financial concerns.
Scheduled to begin with the 2008-2009 school year, the ini-
tiati\'e will result in the awarding of an additional $3 rrdlhon in
HMS scholarship funds, a nearly 40 percent increase over cur-
rent funding levels. It wlU also exclude parents' retirement sav-
ings from the ehgibihty equation, aUov^dng a larger number of
families to qualify for financial support. And the Strategic Advi-
sory Group on Education has joined with the Program in Med-
ical Education and the Committee on Financial Aid in studying
the feasibihty of replacing some of the School's current subsi-
dized federal and institutional loans with scholarships.
"The issue of student debt is of great concern to me, which is
why I feel particular satisfaction with this first step toward
making HMS more affordable," Fher says. "It is important that
the School not be out of reach to a broad segment of
*••••, undergraduate students and their famQies." ■
Connecting the Docs
,• THE HARVARD MEDICAL ALUMNI BULLETIN *.
•* has launched a website aimed at better connecting HMS *•
> graduates with one another and with the School.
In addition to a continually expanding selection of Bulletin archives, the
website offers three sections that curate the magazine's features:
"Fascinoma," which borrows from medical slang to collect articles on
such topics as music and medicine, history's medical mysteries, and
white coat humor; "On Doctoring," which presents articles in areas of
interest to working physicians; and "On Discovery," which captures the
research findings of Harvard doctors.
Other sections include "Alumni Resources," which highlights benefits
the School offers its graduates (such as continuing medical education
discounts and financial aid programs), and "Connect the Docs," which
provides links to alumni websites and blogs; news and features about
alumni; and plot synopses of past Second Year Shows.
The Bulletin website can be found at
http://alumnibulletin.med.harvard.edu. Please send us links to alumni
websites and blogs, information about published books that should
, be added to our online bookstore, lyrics or links that will enrich
*• the Second Year Show archive, and any •'
•, suggestions you may riave. ■ ,•
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
=»f:^'
Lesson Plans
HETHER RAPPING THEIR WAY
L%Tnfl through anatomy class or
^^^fl exploring an imaginary island,
the Class of 2010 proved that
HMS students have brains and talent in
their production of the 101st annual Sec-
ond Year Show. Directed by Andrew Chao
and Camille Powe, All 1 Really Need to Know I
Learned in Medical School cleverly skewered
the class's experience as guinea pigs of the
new integrated curriculum — with song,
dance, and witty dialogue.
The show unfolded as a collection of
earnest first years — an overeager pedi-
atrics student, an awkward social medi-
cine groupie, a geeky Health Sciences and
Technology student, an insensitive
cultural competence advocate, and a ^
dental student with bad breath —
arrive on campus and introduce
themselves with "Our First Day,"
sung to the tune of the Sesame Street
theme song (It's our first day / Off to
learn the Harvard way / On our way, to
where we fight disease). Soon, however,
the students become plagued by self-
doubt as they learn one of them has been
admitted to HMS by mistake.
The opening act focused on the students'
journey through their first year, complete
with the usual mercUess send-ups of favorite
preclinical instructors. "Heart Attack," a
spoof of Justin Timberlake's "SexyBack,"
let muscle-bound surgery professor Dana
Stearns show off his biceps while per-
forming CPR. Perky biology instructor Jen
Stanford summarized the "Key Points" of
the show at various intervals. And anti-
tobacco crusader Allan Brandt (here, a
chain smoker) transported the first years
to a make-beheve island where social
medicine superstars Paul Farmer '90
and Jim Kim '86 were camped out with
Hollywood superstar Angelina Johe,
there to adopt her 17th child.
The show's theme loosely fol-
lowed Robert Fulghum's book All
I Real!}' Need to Know I Learned in
Kindergarten by higUighting life
10
L(
,;j.!>"
K X
GETTING THEIR KICKS: Alexis Moore and Dan Drzymalski
get into the swing of things during the Dance Off of Doom
(above), while Steve Porter (as Paul Farmer) strikes a pose.
lessons apphcable to both kindergarten and medical
school, such as apologizing when you hurt someone. The
show was infused with bits of comedic inspiration,
including a suspiciously sniffling Big Bird — recently
returned from Southeast Asia — and a series of amusing
"training fffms" about the patient-doctor relationship.
The most memorable feature of the show, though, was
the Class of 2010 itself. As the Health Sciences and Tech-
nology student, for example, Marc Walker used impecca-
ble comic timing to deliver such lines as, "I can't wait to
meet a patient. And then maybe when I finish my PhD, I'd
like to meet another one." And Ashley Orynrich, as the
dental student with halitosis, gave a sultry rendition of
"It's Not that Easy Lovin' Teeth," set to the tune of Kermit
the Frog's "Bern' Green."
And who was the mistake? No one, of course,
because HMS faculty would never make a mistake.
They were simply trying to teach the students an
"integrated life lesson." ■
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
ptit.se
MAKING THE ROUNDS AT HMS
Sickness, Wired
CHOLERA, SMALU>OX, AND
other contagious diseases
are now just a few key-
strokes away. Their pres-
ence, thankfully, is virtual,
part of a comprehensive
new digital library collec-
tion mode possible by the
Francis A. Countway
Library of Medicine and
other Harvard-affiliated
libraries.
The online collection,
Contagion: Historical Views
of Diseases and Epidemics, documents the scientific, historical, and social
forces behind the development of contagion theory and modern epidemiol-
ogy and details several "disease episodes," including epidemics of
syphilis, cholera, plague, yellow fever, influenza, and smallpox. Visitors
to the project's website have access to thousands of relevant materials,
including digitized copies of books, serials, pamphlets, incunabula, manu-
scripts, and illustrations. The Countway's many contributions include
unique resources: a letter from Thomas Jefferson to Benjamin Waterhouse
discussing inoculation against smallpox; the first printed medical book to
contain illustrations; and graphic works by such notable caricaturists as
George Cruikshank and William Hogarth.
Contagion, which was created by the Harvard University Library
Open Collections Program, can be accessed at http://ocp.hul. harvard,
edu/contagion. ■
A Man of Vision
IT SEEMS ONLY FIHING THAT MARK HUGHES '86, CHAIRMAN OF THE
Alumni Fund, should succeed the acting chair, Daniel Federman '53.
After all, Hughes played Federman in his class's Second Year Show, "The
Right Stiff." Federman now likes to introduce the new chair by telling a
story about a secondary role Hughes played with the show.
"As a student," Federman says, "Mark visited Carl Walter '32, the
founding choir of the Alumni Fund, to solicit Carl's annual gift to the Sec-
ond Year Show. Mark come away with a doubled gift and Carl's predic-
tion that HMS would get a lot out of Mark in the long run. That long run
begins now."
Hughes maintains on ophthalmology practice in which he specializes
in retinal disease. An early adopter of angiogenesis inhibition for macular
degeneration, he has been widely published in the areas of ophthalmology
and professional standards in medicine. ■
Gained in Translation
ARVARD MEDICAL SCHOOL HAS
received a five-year Clinical
and Translational Science
Award from the National
Institutes of Health to launch a center
that will transform patient-oriented
research and create an unprecedented
level of collaboration across the Har-
vard schools and affiliated hospitals
and institutes. With this award, the
University will join a consortium of
clinical and translational science cen-
ters based at academic health institu-
tions around the country.
The Harvard center will be directed
by Lee Nadler 73, the Virginia and D. K.
Ludwig Professor of Medicine at the
Dana-Farber Cancer Institute and HMS,
and co-directed by Steven Freedman 73,
HMS associate professor of medicine at
Beth Israel Deaconess Medical Center.
HMS will receive $23.5 miiUion armuaUy
during the five-year period. The School,
University, and affiliated hospitals have
also joined together to contribute an
additional $15 million to the effort.
"This is an extraordinary moment for
our University, our School, and all of the
hospitals and institutes that make up
the Harvard Medical community," says
Jeffrey Fher, dean of HMS. "The grant
apphcation required an unprecedented
level of collaboration across our commu-
nity, as well as a commitment to a broad
and compelling \'ision of clinical and
translational research at Harvard."
Among the initiative's key strategies
will be to improve communication across
the University and to help clinical investi-
gators locate tools, equipment, collabora-
tors, and expertise throughout the Har-
vard system. "Thanks to the efforts of Jeff
Fher and Lee Nadler," says Steven Hyman
'80, provost of Harvard University, "we'U
be able to put together a bench-to-bedside
translational and chnical research effort
that will make the Harvard medical sys-
tem bigger and more effective than the
sum of its storied parts." ■
10
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
PRESTDENT^S REPORT
k^
The Strongest Link
N THE JUNE 1928 ISSUE OF THE BULLETIN, JOSEPH
Garland, a member of the Class of 1919 and the
magazine's founding editor, begged the School's
graduates to send news of themselves. "Our col-
umn of Alumni Notes, brave enough a few months ago," he
wrote, "has shrunk now to such proportions that we won-
der if the graduates of the Harvard Medical School are
entirely inactive in the arena of life, never even changing
their addresses, or if modesty or fear of their local commit-
tees on ethics and discipline prevents them even from
announcing through our columns that little Mary Jane has
come to gladden the hearts of both parents. The editor is
tempted — almost — to insert his own name with the news
that he has not bought a new fountain pen because the old
one is still working."
"Connect the Docs," or a newly available alumni resource —
and offer other relevant information, including details about
upcoming reunions and news about individual alumni.
We also envision an e-community with even greater poten-
tial, one that wiU help us foster such initiatives as the cultiva-
tion of mentoring relationships between students and alumni,
a clearinghouse of alumni willing to host students interview-
ing for residencies outside of Boston, an exploration of service
opportunities, and a forum for discussions on important issues
in health care and medical education.
My successor as president, Steven Weinberger '73, shares
my interest in buHding this alumni interaction space. We hope
that our work in developing online connections will prove as
successful as several other recent Alumni Council initiatives.
When Steven Schroeder '64 served as president, for example.
We also envision an e-community that will help us
foster such initiatives as the cultivation of mentoring
relationships between students and alumni.
Eighty years later, we find ourselves making the same plea
for alumni to stay in touch with the School — and with each
other. But we now have communication tools far more elab-
orate than Garland's trusty fountain pen, and we are hoping
to exploit them to bring members of the Harvard Medical
School community a little closer to one another, no matter
their geographic address.
During my tenure as president, I have worked with Council
members to estabhsh a virtual community of HMS alumni. A
year ago the Harvard Medical Alumni Association redesigned
and retnvigorated its website, and now the Bulletin has an online
presence as weU. We have been working with Post.Harvard,
the University-wide alumni website, to create additional
avenues for communication. These websites are a good begin-
ning; not merely a database, each has been designed with the
goal of bringing alumni together. The Bulletin's "Connect the
Docs" section in particular is aimed at forging links among
alumni, faculty, and students.
But these websites represent only a sliver of what we hope
to provide. We plan to launch an e-newsletter, for example,
that will bring content updates to interested alumni — such
as the online availability of the latest Bulletin, irmovations in
he brought his passion and energies to bear on the issue of stu-
dent debt, and the Council helped spark renewed attention to
reheving the financial burden on HMS students. And last year,
A. W Karchmer '64 led the Council in working with Sanjiv
Chopra, the faculty dean in the HMS Department of Continu-
ing Education, to develop some terrific continuing education
benefits for HMS alumni.
Although these legacies serve to define the contributions of
past presidents and Council members, the issues they tackled
were ones that drew on the concerns — and wishes — of many
alumni. We beheve our efforts to pull graduates together using
today's communication tools also respond to those needs and
hopes by helping alumni remain grounded in their profession
and linked to their classmates while they circle the globe on
their missions of healing. ■
William W. Chin 11 is vice president for discovery research and clinical
investigation at Eli Lilly and Company.
The Bulletin's website can he accessed at http://alumnihulletin.mcd.
harvardedu; to learn more about the Har\'ard Medical Alumni Association,
visit Mrmv.hms.harvard.cdu/alumni.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
11
SPARKS OF TNSPTRATTON
12
Deliver the Goods
ECADES HAVE PASSED, YET THE CONVERSATION STILL
resonates with Donald Berwick 72. "Joanne's story
was a turning point for me," he says. "It showed me
our approach to health care reform was bankrupt."
Joanne, an administrator in a radiology department at
Harvard Community Health Plan, had sent Berwick data
showing that in a three-month period, her department had
slashed patient waiting times from an average of 45 minutes
to 2 minutes. Berwick simply had to know the details behind
her success. So he had gone to her office.
"Joanne, you've knocked the socks off this problem!" he
exclaimed. "What did you do?"
Joanne looked at him; "It was easy. All I did was lie."
Color Coded
At the time, Berwick was the group's vice -president for quah-
ty-of-care measurement. Joanne had sent her data in response
to an assessment survey he had circulated. From Berwick's
shocked expression she knew a fuller explanation was needed.
"Let me tell you what happens around here," she said.
"When I send you data that shows all the problems, you send
that to my boss's boss's boss, and he circles it with red ink.
Then he sends it to my boss's boss, and he circles it in yeUow
marker and sends it to my boss, who circles it in orange ink and
writes, Joarme, do something about this.' It then comes back to
my desk — as if I didn't know we had a problem and wasn't
akeady doing everything I could to resolve it. So I made up the
data. I knew both you and I would be happier if I did."
Her story opened Berwick's eyes. "I saw that so long as we
kept beating up the workforce," he says, "so long as we just kept
asking good people to try harder to fix chronic issues, we'd
never, ever get going. This upended my whole way of thinking."
Berwick, a clinical professor of pediatrics and health care
pohcy at Harvard Medical School, has dedicated himself to
changing the way people approach health care improvement.
He beheves he has struck upon a better way to work for the
Joannes out there — and for aU the patients she and so many
other health care professionals seek to serve while operating
within a hobbling system. In his approach, problems associated
with the practice and deUvery of health care — problems like
medical errors, waste, and a systemic inability to look inward
and learn — are dissected as problems of process, not of people.
And, taking a page from industry's push to improve productiv-
ity, workplace morale, and product quahty, he encourages the
health care industry to foUow a new paradigm.
With searing clarity, Berwick points out the flaws of the
health care system and analyzes how they can be overcome
through redesign. He and the growing legion of hospitals and
health professionals that work with him have shown that
specifying processes and streamlining systems can avoid need-
less deaths, alleviate pain and suffering among patients, elim-
inate waiting and waste, and help banish the helplessness
that patients and their families too often experience.
Most health professionals are painfully aware of the need for
improvement. If they aren't, numbers might help convince them.
A patient safety study conducted between 2004 and 2006 by
HealthGrades, a health care ratings organization, presented data
on the costs of medical errors gleaned from an analysis of 41 nul-
hon records of Medicare patients. Its findings showed that
patient safety errors resulted in nearly a quarter of a miUion
preventable deaths during the period studied. It further found
that more than 60 percent of the common medical errors report-
ed involved bedsores, failure to save patients once complications
arose, and postoperative respiratory failure. With fewer such
errors, the study analysts estimated thousands of hves and up
to $2 bilhon in outright costs could have been saved.
Industrial Strength
The idea for applying the principles of what is known as con-
tinuous quahty improvement to the service-based industry of
health care came to Berwick in the mid-1980s, soon after Joanne
had confessed the secret behind her success. Berwick had reg-
istered for a weekend lecture series in Washington, DC, featur-
ing W Edwards Deming, a mathematical physicist who had
successfully appUed statistical methods to industrial quahty
control questions. Largely unsung in the United States, Deming
was a hero among Japan's industriahsts who had used his theo-
ries to propel that nation's postmodern economic boom.
"For the first day and a half, " says Berwick, "I sat there lis-
tening to Deming explain his statistics-based, engineering-
based theory for how proper management should work to
achieve continual improvement. By noon of the second day I had
left and flown back to Boston. I thought it was all nonsense."
But the night of his return proved to be a restless one for
Berwick. Agitated, sweating, and unable to sleep, he wan-
dered into his living room and sat down to think.
"Suddenly it hit me," he says. "I realized my discomfort wasn't
the result of my being exposed to a theory that was wrong. I
was uncomfortable because what I had heard made sense to
me — and it violated almost every theory that I had been fol-
lowing. I returned to DC and completed the seminar."
Berwick walked away from this epiphany with an idea for
fixing health care that was unKke almost anything that had yet
been tried. In 1987, his innovation led to a role as co-principal
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
MOMENTS THAT HAVE IGNITED INNOVATIONS IN MEDICINE
investigator on an experiment known as the National
Demonstration Project on Quality Improvement in Health
Care. Teaming with A. Blanton Godfrey, who was then a qual-
ity management theoretician with Bell Laboratories, Berwick
set out to test whether methods used to improve industrial
quahty were apphcable to health care. Berwick and Godfrey
matched 21 professionals from health care organizations with
a similar number of industrial quality assurance professionals
from academia and industry.
After 18 months of work, the groups reported their results
on projects ranging from better billing procedures to improved
ways of transporting infants between hospitals. The results
were so stunning that the study sponsors granted the investiga-
tors funding for three more years. The researchers used the time
to estabUsh a network of hospitals that shares information on
implementation efforts, to inaugurate forums on quality
improvement in health care, and to develop courses on how to
adapt industrial quahty improvement methods to health care.
To spread the word further, in 1989 Berwick wrote a com-
mentary for the New England Journal of Medicine. The title,
"Continuous Improvement as an Ideal in Health Care," only
hints at its true purpose: It is at heart a manifesto declaring the
need for the profession to look anew at itself and its approach
to improvement. Berwick oudines why an approach that
blames problems of quahty on workers' poor intentions only
serves to make people game the system — distort the data, fault
others for perceived shortcomings, and fearfully avoid anyone
associated with quahty measurement and improvement.
On the other hand, Berwick points out, if problems with
quahty are seen for what they truly are — fundamental flaws of
a complex system — they can be understood and re\dsed on the
basis of data about the processes themselves, not the people
implementing them. The potential for improvement in quahty
is nearly boundless, Berwick says, if we remove fear from the
equation, learn from accurate information, and enhst the tal-
ents and spirit of dedicated professionals.
All Ahead Full
The principles set forth in his article are ones Berwick
applies in practice. In his work at the Institute for Health-
care Improvement, a not-for-profit organization in Cambridge,
Massachusetts, that he helped establish in 1991, Berwick has
focused on fixing health care systems in the United States
and abroad. One of the institute's more visible efforts
launched in 2004 when it began a campaign to improve
hospital safety. The 100,000 Lives Campaign was designed
to help hospitals reduce unnecessary deaths by encouraging
them to implement over a two-year period a handful of sci-
entifically proven improvements in care delivery, such as
rapid response teams for critical care interventions, the pre-
vention of surgical site and central-line infections, and the
reduction of medication errors.
The campaign exceeded its goal: Hospitals participating
in the campaign and in other initiatives prevented an esti-
mated 122,300 unnecessary deaths within an 18-month cam-
paign period. In December 2006, the Institute for Healthcare
Improvement launched a second such effort, this time with a
goal of preventing five million incidents of medical harm in
the United States.
With initiatives to transform medical and surgical care,
perinatal care, clinical office practice, surgical outcomes, and a
host of other improvements, the work of Berwick and his
team is steaming ahead. Berwick knows, though, that the
task is great and that protracted implementation means more
lives lost, more frustrated health professionals, and a contin-
ued escalation of costs in an increasingly inequitable health
care system. Incremental change, he feels, is not the answer.
Instead he believes the U.S. health care system needs funda-
mental change. And if that means building it anew, well,
Berwick may just be the one to spark that transformation. ■
Ann Marie Mcnting is associate editor of the Har\'ard Medical
Alumni Bulletin.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
13
ROOKSHET.F
BOOKS BY OUR ALUMNI
CHILDREN
DIVORCE
The
Metabolic
Syndrome
and
Obesity
sSiS
Manual ol
Pediatric
Tiierapeuiics
1
sr&r ■
" ■ "' ■
i
Cardiovascular Disease in the Elderly Manual of Neonatal Care
edited by Wilbert S. Aronow '57,
Jerome L. Fleg, and Michael W. Rich
(Fourth edition, Informa Healthcare, 2008)
People older than age 65 currently
account for more than 80 percent of all
cardiovascular disease-related deaths.
The updated version of this classic
textbook provides a comprehensive yet
readable overview of the epidemiology,
pathophysiology, evaluation, and treat-
ment of cardiovascular disorders in this
population. The book offers an in-depth
discussion of the elderly patient in the
clinical setting and considers the impact
of coexisting conditions, polypharmacy,
frailty, and patient preferences on cardio-
vascular disease management.
Children of Divorce
A Practical Guide for Parents, Therapists,
Attorneys, and]udges, by William Bernet '67
and Don R. Ash (Second edition,
Krieger Publishing, 2007)
Because every divorce has social, psycho-
logical, and legal implications, this guide
speaks to all the major players — parents,
therapists, attorneys, and judges. The
expertise of both psychiatric and legal
professionals is presented, and the book
offers readers advice to achieve three
basic goals: to help children maintain
good relationships with both parents; to
help children continue to maintain their
regular routines; and to help children
learn how to accept inevitable losses and
disappointments and then move on.
by John R Cloherty, Eric C. Eichenwald
'84, and Arm R. Stark '71 (Sixth edition,
M)ItersKluwef;2007)
This revised volume offers a practical
approach to the diagnosis and medical
management of problems in newborns.
The book contains new information on
fetal assessment, new guidelines on the
management of neonatal jaundice, and
updated data on the survival of prema-
ture infants and perinatal asphyxia.
Intubation and sedation guidelines and
an easy-to-access guide to neonatal resus-
citation are also included.
The Metabolic Syndrome and Obesity
by George A. Bray '57 (Humana Press, 2007)
Bray's survey of the current scientific
understanding of obesity and the meta-
bohc syndrome also includes an overview
of the most significant changes in the
field during the past 30 years. This com-
prehensive reference addresses the prob-
lems and offers solutions. Treatment
options such as diet, exercise, behavioral
therapy, surgery, and pharmaceuticals
are also discussed.
Where Did All the Fat Go?
The WOW. Prescription to Reach Your
Ideal Weight — and Stay There, by Robert
Huizenga '78 (Tallfellow Press, 2008)
Based on new obesity research, this
book provides readers with the same
successful diet and exercise program
the author offers as the doctor for the
NBC television show The Biggest Loser.
He also addresses the psychological
aspects of obesity and weight loss,
including depression, temporary set-
backs, emotional problems, and pitfalls
and barriers.
Manual of Pediatric Therapeutics
by David S. Greenes '91 (Seventh edition,
Walters Khwcr, 2008)
Based on the experience of clinicians at
ChUdreris Hospital Boston, this practical,
point- of- care reference contains current
information on topics such as acute care,
behavioral disorders, and management of
children with developmental disabilities
and other specialized health care needs.
An A-to-Z drug formulary is included.
Lifting the Weight
UnderstandingDepression in Men, Its Causes
and Solutions, by Martin Kantor '58
(Praeger Publishers, 2007)
Long thought of as a "feminine" disorder,
depression actually affects millions of
men each year. In this jargon-free text,
Kantor focuses on the human dimension
of depression as it appears in men,
emphasizing the "microscopic doings of
the depressed maris inner and outer life."
He takes a hohstic approach, melding
various schools of thought with his clini-
cal experience. The author also includes a
chapter on how to cope with men who
are depressed.
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
REVIEWING THE PRINTED WORD
BOOKMARK
8 Weeks to Optimum Health
A Proven Program for Taking Full Advantage of Your Bodys
Natural HcalingPowcr, by Andrew Weil '68
(revised paperback edition, Ballantinc Books, 2007)
Y CHILD LIKE YOURS IS PERFECT IN EVERY WAY,
except that she does not take my advice. For reasons
I fully understand (yet cannot fuUy accept), she will
not look to my years of cuUed professional knowl-
edge and life experiences to guide her physical and mental
health. There is no glow of the follower in her loving eye. She
would rather suffer and learn on her own. She is stiU young.
Lucky Andrew Weil '68. He has followers eager to learn
from his knowledge and experiences. Perhaps this has
caused a certain confidence. "If," he writes in his revised and
expanded 8 Weeks to Optimum
Health, "you are motivated to
read this book and begin the
program, you need no other
outside help." A lovely idea it is.
Readers of the Bulletin and
0, The Oprah Magazine already
know Weil as an expert in
integrative medicine, a prolific
writer, and a personality with
a strong and jolly twinkle in
his media-sensitive eye. The
book is intended as a guide for
the general audience. Each
week, Weil assigns home-
work: one new project (purify
the water, lean toward organ-
ic produce); one new piece of
dietary advice (add salmon,
soybeans, green tea); one new
supplement; sequential walking and breathing techniques; and
one spiritual recommendation (buy flowers, visit a park). There
are also optional exercises — extra credit for the soul — and
recipes. Two hundred and sixty-four pages boil down to this
counsel: be good to yourself and others. The rest is merely detail.
When the first edition of the book emerged a decade ago,
this advice, especially the details, seemed revelatory. It is in part
the result of Weil's efforts that most of his guidance now seems
merely sensible. Alternative and integrative treatments are pro
forma; Harvard itself has a whole division dedicated to their
research and practice. And the influence of mind upon body is
also indisputable, as Weil's work has helped show.
His special interest is the healing system, which, he
explains, is not structural but functional. It is more inclusive
than the Western medical model, expanding to include soma.
psyche, and spirit, and operating from the level of DNA "up to
the level of cut fingers, and into the mental realm, where it
helps us adjust to emotional shocks." This is the kind of phi-
losophy you either believe or you don't.
To Illustrate its potential. Well begins his book at his ovvm
begiiming: an overweight, over-burdened person. His diet was
"free form and thoughtless." His mind was "restless [and] sus-
ceptible to boredom." He suffered from hives, migraines, and
sunburns. The treatment he needed was not medicine but a
lifestyle adjustment. He made that adjustment and now offers
the same treatment to others. "Patients come to me with sto-
ries of woe," he explains, "and instead of giving them magical
cures, I tell them they must change their diets, habits of exer-
cise, ways of handling stress, even their breathing."
The testimonials in each chapter are not as interesting as
Well's writings about alternative treatments. His chapter on
tonics includes wonderful descriptions of herbs with poems
for names (ashwagandha and
cordyceps) and an unexpect-
ed endorsement of aspirin.
He informs us that more than
400 compounds contribute
to ginger's smell, taste, and
biological activity, and that
coenzyme Qjg should be taken
with a fatty meal to increase
bioavailability. This informa-
tion is useful, at least to
the believer.
But the program has some
problems. Some of the advice
is dated (ginseng has seen
better days). Also, it is easiest
for those followers with both
feet on firm financial ground.
In the shelters where I work,
patients cannot afford many
of Weil's suggestions, including wild Alaska salmon,
saunas, and hypnotherapists. And whUe I am quibbling, there
is something about a recipe for "Dr. Andrew Weil's Favorite
Low-Fat Salad Dressing" that sends a rebel straight to the
high-fat salad dressing section of the supermarket. Too much
first person can brmg out unspiritual and belittling tenden-
cies in a reader. This is a shame, as the book was written for
my own good.
As I finish this, my daughter is refusing my suggestions for
organizing her fourth- grade homework folder — again. It could
use help. Her refusal does not discourage me, since I am never
tired of giving advice. Interestingly, though, I'm sometimes
tired of getting it. ■
Elissa Ely '88 is a psychiatrist at the Massachusetts Mental Health Center
SPRING 2008 • HARVARD MEDICAL AlUMNI BULLETIN
15
ENCHMARKS
I DISCOVERY AT HMS
Adjusted to Fit
OAXING THE BODY TO TOLERATE
transplanted tissue usually
depends upon chemical induce-
ments. These pharmaceutical
aids can be taxing, though. For one thing,
the transplant recipient must take the
immunosuppressive drugs for the rest of
his or her life. Yet even with perfect
adherence, the drugs can fail in their
task, leading the patient's immune sys-
tem, unconvinced of the merits of the
new tissue, to reject the transplant.
Research from a team at Massachu-
setts General Hospital, however, may
have struck upon a way to ensure toler-
ance of kidney transplants without the
long-term assistance of immunosuppres-
sive drugs. The team's irmovation relies
on a quick succession of therapies that
trick the immune system into accepting
the new tissue as friendly rather than
foreign. And perhaps most promising of
all, the method is the first to work for
patients and donors who were immuno-
logically mismatched, a situation that
can comphcate transplantation efforts.
The senior researcher for the MGH
team was David Sachs '68, the Paul S.
Russell/Warner-Lambert Professor of
Surgery and director of MGH's Trans-
plantation Biology Research Center; the
team also included Nina Tolkoff- Rubin
'68, a professor of medicine and director
of hemodialysis at the hospital. Their
report appeared in the January 24 issue
of the New England Journal of Medicine.
Preparation Is Everything
The team designed the study with pre-
and postconditioning routines that they
hoped would create a temporary state
in which bone marrow stem cells from
the donor would mix easily with those of
the patient. The stem cells in a person's
bone marrow spawn an array of other
cell types that populate the body's
immune network.
In the chimeric state the researchers
sought to induce, the bone marrow stem
cells of the patient would form an
alhance with introduced bone marrow
cells from the donor. The mixed cells
could then work to broker an amiable
coexistence between the new tissue and
the body's immune sentinels. If all went
well, the patient's immune system would
be tricked into accepting the donor kid-
ney forever.
To ease this transition, the team pre-
conditioned each patient with a regi-
men that used chemotherapy to partially
destroy patients' bone marrow; an anti-
body to disable immunologically active
T cells, which form in the thymus; and
irradiation of the thymus to further sup-
press T cells. After transplantation and
an infusion of donor bone marrow,
patients were isolated for two weeks
in a sterile room to allow cells in the
bone marrow and the immune system
to regenerate.
The team enrolled five patients with
end-stage renal disease who were
scheduled to receive a kidney from an
immunologically mismatched parent or
sibling. The first two patients respond-
ed well to the preconditioning, trans-
plantation, postsurgical isolation, and a
nine- to fourteen-month weaning from
immunosuppressive drugs.
A third participant, however, rejected
the transplanted organ and had to under-
go a second transplant. This rejection
might have clouded the team's effort had
they not discovered the patient's B cells
had raUied to fight the new organ's pres-
ence. In most cases, B cells, which devel-
op in the bone marrow, depend on T cells
to activate. In this patient, reactive B cells
may have already existed.
16
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
Weapon for Mass Construction
By revising the plan to include a
B' cell-depleting antibody in the precon-
ditioning protocol, the team used the
regimen successhally for the final two par-
ticipants. Of the four patients for whom
the study regimens worked, all have had
stable renal function for two to five years.
"This marvelous work exemplifies the
progress occurring in the field," says
Joseph Murray '43B. "It is simply mind-
bogghng the way advances have manifest-
ed themselves in the decades since the
first soHd-organ transplantations." In 1954,
Murray was surgeon for the team that per-
formed the first successful human organ
transplant. Four decades later, Murray,
together with E. Donnall Thomas '46,
received the Nobel Prize in Physiology or
Medicine for pioneering work in the field
of organ transplantation.
Matched Set
Across the country, another HMS alum-
nus has broken new ground in the field.
Samuel Strober '65 was senior researcher
on a Stanford team that also reported
findings on immune tolerance of organ
transplants in the January 24 issue of the
New England journal of Medicine.
Unlike the MGH effort, the Stanford
team focused on transplantations involv-
ing matched donors and patients. The
study rehed on a post-transplantation reg-
imen of lymphoid irradiation and antithy-
mocyte globulin, an antibody that fights
tissue rejection by blocking the actions of
T cells, to adjust each patient's immune
system to accept the new tissue. After ten
days of the regimen, patients were infused
with blood stem cells from a compatible
donor and a state of persistent chimerism
was achieved. Of the six patients in the
study, one has been off all immunosup-
pressive drugs for more than two years.
According to MGH's Sachs, the stud-
ies' findings could offer patients hves free
of the problems — and cost — of immuno-
suppressive drugs. ■
\
RENOVATION AND RENEWAL OF BONE
diminished by age or disease could
be just around the corner, according
to results from a study by scientists at
Massachusetts General Hospital and
the Harvard Stem Cell Institute. A
team of researchers wrote in the Feb-
ruary issue of the Journal of Clinical
Investigation that a drug used as a
targeted chemotherapy in patients
with multiple myeloma helped regen-
erate bone tissue in mice by activat-
ing stem cells critical to the formation
of new bone tissue.
The findings could represent a novel
therapeutic strategy for bone diseases:
targeting stem cells using drugs. If
so, this news may one day help put
the spring back in the step of post-
menopausal women who suffer from
osteoporosis or individuals who have
lost bone mass because of cancer.
The team of investigators led by
Siddhartha Mukherjee '00, on HMS
instructor in medicine at Massachu-
setts General Hospital's Center for
Regenerative Medicine and Technolo-
gy, set up their study to examine the
effects that the drug bortezamib
might have on cells known as mes-
enchymal stem cells (MSCs). Found
in bone marrow, MSCs are multipo-
tent; that is, they can develop into
any of several types of cells. If trig-
gered during their more impression-
able period, they can become bone,
fat, muscle, or cartilage cells that can
then grow or repair tissue lost to dis-
ease or trauma.
The team selected bortezamib
because clinical evidence from multi-
ple myeloma patients taking the drug
showed elevated serum levels of
alkaline phosphatase and osteocal-
cin, substances linked with bone for-
mation. Hoping to isolate how the
drug's actions might contribute to
increased bone formation, the
researchers tested possible targets for
the drug. Surprisingly, they found it
caused MSCs to form bone tissue.
The in vivo mouse model the scien-
tists used was one developed for
menopausal osteoporosis. When
they treated these mice with low
doses of bortezamib, doses equiva-
lent to between one-fifth and one-
third what would normally be consid-
ered effective against tumors, they
found an increase in bone formation,
in the mineralization of spongy tissue
matrices that form the ends of long
bones such as the femur, and in the
production of osteoblasts, the cells
that make up bones. Similar results
were achieved when the researchers
tested the drug in vitro on cultured
MSCs derived from human bone
marrow and from mouse models.
The authors point out the drug's
potential for people experiencing
bone loss. In addition, they note the
study offers proof of principle that a
drug can harness the inherent power
of the body's stem cells to repair
and regenerate tissue — a strategy
that might become increasingly key
to regenerative medicine. ■
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
RENCHMARKS
I DISCOVERY AT HMS
Not Even Death Is Certain
T'S NOT QUITE AS UNIVERSAL AS
one might expect. How to
determine brain death, that is.
Although the American Acad-
emy of Neurology (AAN) has weighed in
on the subject, a report in the January 22
issue of Neurology found many of the
nation's top-ranked neurology and neu-
rosurgery centers differ considerably in
how they apply the AAN's guidelines.
And the researchers found some institu-
tions had no guidelines at all.
The members of the research team
designed their study after they became
curious about what they viewed as major
discrepancies among such pohcies in cer-
tain hospitals. So they set out to gather
and compare protocols on brain death
determination from 50 hospitals hsted
high in U.S. News and World Report's 2006
ranking of neurology and neurosurgery
centers. The team was led by David Greer,
an assistant professor of neurology at
Massachusetts General Hospital, and
included researchers at the Mayo Clinic
in Rochester, Minnesota, and the Henry
Ford Hospital in Detroit, Michigan.
Their interest, and indeed that of med-
icine in general, in the issue of brain
death has its roots in questions raised in
the late 1950s by two French physicians.
Their published descriptions of 23
patients in unending comas spawned the
concept and gave rise to a definition: the
irreversible loss of all brain function
while systemic organs remain artificially
supported. Equating brain death with
standard concepts of death came in a
1981 Presidential Commission on ethical
problems in medicine. It stated that
brain death was the legal equivalent of
such long- accepted measures of death as
cessation of heart and lung function.
Currently, most states have enacted
what is known as the Uniform Determi-
nation of Death Act, which specifies that
determinations of brain death be made
according to accepted medical standards,
be they national, regional, or local. In an
effort to create a norm for such guidelines.
in 1995 the AAN published practice
parameters based on an evidence-based
review of the Uterature and best practices.
Dead Reckoning
The researchers used five categories of
the AAN practice parameters as points
of comparison: guideline performance,
preclinical testing, clinical examination,
apnea testing, and ancillary tests.
Among the 41 responding institutions,
three had no policy at all. For the
remaining 38 hospitals, the researchers
found a surprisingly low percentage (42
percent) required either a neurologist or
a neurosurgeon be present during the
determination. Of these, only 35 percent
required an attending neurologist or
neurosurgeon be present.
Nearly three-quarters of responding
hospitals required multiple examina-
tions — 3 percent sought more than
two — wtule allowable time between
examinations varied from 1 to 24 hours,
with 6 hours being the most common.
More than 95 percent of the responders
required preclinical tests but differed
widely in what tests they recommended:
estabhshing an underlying cause (63 per-
cent); ensuring the absence of sedatives
and paralytics (55 percent); verifying the
18
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
absence of acid-base disorders (45 per-
cent); or ensuring the absence of endocrine
disorders (42 percent).
Although apnea testing was missing
from one group's guidelines for clinical
examinations, guidelines that did include
it stipulated a variety of techniques for
such testing. Lowest acceptable tempera-
ture, for instance, was specified in only
26 percent of the guidelines; 66 percent
required an arterial blood gas prior to test-
ing; and 76 percent stated preoxygenation
was mandatory, although the method for
doing this was unclear in 69 percent. As for
information related to ancillary testing, 66
percent of the guidelines specified when it
was necessary. And although specific tests
were often mentioned, such as EEGs (84
percent), the details of how the tests were
to be administered were less common —
only 33 percent mentioned EEG specifics.
Grave Differences
Although Greer and his team were
encouraged by the rate of response from
hospitals they contacted, they were dis-
turbed by the variation they discovered.
"We were surprised to find such signifi-
cant differences among these hospitals in
terms of their guidelines for brain death
determination," says lead author Greer.
"We anticipated more consistency with
the AAN's practice parameters."
In pointing to the ethical as weU as the
medical-legal imphcations of such vari-
abihty, the team underscored how wide-
ranging guidelines can have unfortunate
consequences, such as the administration
of inappropriate treatment to patients
who have been labeled brain dead. Noting
that the AAN's practice parameters are
more than a decade old, the researchers
suggest a revision may be in order and
that the results of their study could be
used to inform such an effort. They also
propose the development of web-based
checklists or other new tools that could
aid physicians who must make brain
death determinations. ■
1 111^
1 1 111^
Research Digest
ABSENCE NOTED
A research consortium that includes Mass-
achusetts General Hospital has found that
the deletion or duplication of a section of
chromosome 1 6 may be a strong risk fac-
tor for autism. The researchers scanned
DNA from more than 1 ,400 affected chil-
dren and a similar number of unaffected
parents and found an identical region of chromosome 1 6 was missing in five
individuals with an autism disorder. Data from a separate group of 1 ,000
patients from Children's Hospital Boston showed that among participants with
a diagnosis of autism or a related developmental delay, five had the same
deletion and four others had a duplication of the section. The work appeared
in the February 14 issue of the New England Journal of Medicine.
WEED-BE-GONE
When oncologists talk of stems and seeds, chances are it's not a botanical
discussion. Tumor stem cells, an immortal mutated cell type, are thought to be
the seeds from which many, if not all, cancers develop. Impervious to all can-
cer-busting therapies, such cells are also rare, making their study difficult.
Their elusiveness may now be threatened. A U.S.-China research team, with
senior investigator Judy Leiberman '81, an HMS professor of pediatrics at
Children's Hospital Boston, has produced large numbers of human breast
cancer cells in mice — and has discovered a genetic switch that decreases
their ability to propagate tumors. The switch, a type of molecule known as a
microRNA, turned off certain genes that helped the cells spread tumors. The
study appeared in the December 1 4 issue of Cell.
WHAT A PAIN
A class of drugs that is one of the more widely prescribed in developed
countries may also be the source of its users' aches and pains. A team of
researchers at Beth Israel Deaconess Medical Center has found that choles-
terol-lowering statins act to increase levels of atrogin-1 , a protein involved in
muscle atrophy. This breakdown of the muscle tissue could, says senior
researcher Vikas Sukhatme '79, the Victor J. Aresty Professor of Medicine at
HMS, explain the range of symptoms, from mild muscle weakness to pain,
reported by people using statins. The study appeared in December's Journal
of Clinical Investigation.
NEW CAST MEMBERS
Researchers have unmasked some unknown genetic players in the regulation
of the blood's levels of cholesterol and triglycerides. In the February issue of
Nature Genetics, an international team, which included scientists from the
Broad Institute of Harvard and MIT, reported associating levels of these fats
with 1 8 genetic variants, six of which had never before been linked with this
activity. Lead author Sekar Kathiresan, an HMS instructor in medicine at
Massachusetts General Hospital and a genetics researcher at the Broad,
notes the findings may offer a way to predict a person's risk for heart disease
as well as open the door to the development of new treatments.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN 19
Did psychiatric illness help
or hinder the creativity
of some of history's most
celebrated composers?
hy Richard Kogan
MAGIC WAND: Leonard
Bernstein's exuberance was
legendary, and audiences
worldwide responded as
much to his performances as
to his orchestral and choral
compositions. "Life without
music is unthinkable, music
without life is academic,"
he once ^rote. "That is
why my contact with music
is a total embrace."
CHORDS OF
DISQUIET
^P^
w.
ERGEI RACHMANINOFF DFDICATED HIS PIANO CONCERTO NO. 2 TO
an unlikely muse: his psychiatrist. The Russian composer had
suffered from a debilitating depression since the disastrous pre-
miere of his Symphony No. J three years earlier, and the illness had
robbed him of his ability to compose music. After his psychiatrist
cured his creative block through hypnosis, Rachmaninoff
produced his second piano concerto, which became arguably
his most celebrated work. The arc of the composition reflects his
emotional trajectory: the piece opens with mournful,
elegiac chords and ends in triumph; Rachmaninoff
marked the tempo of the piece's final section risoluto.
The relationship between Rachmaninoff's illness
and his music intrigues me, for I'm a psychiatrist by day
and a concert pianist by night. Ten years ago, the Amer-
ican Psychiatric Association asked me to give a presen-
tation on the connection between creativity and mental
illness. Until that time, my careers had progressed on
parallel tracks. But that experience helped me appreci-
ate the synergy between the two domains. My psychi-
atric training enabled me to identify patterns of illness
in the hfe stories of the great composers, and this under-
standing gave me insight into the creative process.
Posthumous diagnoses can be tricky, of course; it's dif-
ficult enough to diagnose correctly the hving, breathing
WOLFGANG AMADEUS
MOZART
1756-1791
WOLFGANG AMADEUS MOZART composed symphonies so
effortlessly that he seemed to be taking dictation from
God. Lesser mortals would have suffered writer's cramp
even copying that many notes.
Mozart is indisputably the greatest child prodigy in the
history of classical music. His talents first became e\'ident
when he was three, and by the time he turned five he had
already written short compositions for the clavier. Soon he
had graduated to symphonies. He spent most of his child-
hood on tour, dazzhng kings and queens at imperial courts
throughout Europe with his precocious accomphshments.
While there have been other musical titans, Mozart's
genius set its own exquisite bar. Ludwig van Beethoven
would fill wastebaskets with rough drafts before produc-
ing a final masterpiece. Mozart, by contrast, was capable
of mentally composing lengthy, complex string quartets
while playing billiards.
Mozart's unique talent has inspired much speculation
over the centuries, and scholars have posited various
neuropsychiatric conditions to explain his behavior. The
unending stream of profanities that laced his speech and
correspondence has led some researchers, for example, to
suggest that he had Tourette's; coprolalia, an obsessive
use of obscene language, is an occasional feature of the
syndrome. But there is scant evidence that Mozart
22
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
patients I see regularly in my office. But my exploration
into composers' lives has taught me more about the very
nature of music — and affirmed for me its healing powers.
For all its healing properties, artistic production,
unfortunately, often reflects a darker side. The notion
that mental illness disproportionately affects practition-
ers of art, literature, and music dates to ancient times.
All great artists and philosophers, Aristotle believed,
had to suffer from melancholy. Epidemiologic surveys
have suggested, in fact, that the incidence of mental ill'
ness is somewhat elevated among artists.
It's important, though, not to romanticize the notion
of mental illness as essential to creativity. Johann
Sebastian Bach, Joseph Haydn, and Felix Mendelssohn
are among the members of the classical music pantheon
who seem to have escaped the burden of mental Ulness.
And such maladies as depression are usually too para-
lyzing to be considered an asset to creativity.
Even so, an interplay often exists between illness
and creativity. In Maurice Ravel's most famous work.
Bolero, for example, the seemingly endless repetition of
a single musical phrase dominates. In creating this
work. Ravel was clearly perseverating, an early symp-
tom of the dementia that would eventually overtake
him. He may even have sensed the imprint of his illness
on his work; he once trivialized Bolero as a "piece for
orchestra without music."
The link between mental illness and creativity
requires a special sensitivity in treating mood disorders
in artists. Psychotropic medications can lead to the
blunting of emotional intensity. Some of the artists I treat
have confided they would rather retain their creativity
and suffer than sacrifice their expressive abilities. They
raise a legitimate concern. Would Robert Schumann have
been as productive a composer if he had taken mood
stabihzers for his bipolar disorder?
Music and medicine are both healing arts, and music
has often provided salvation to great composers. It was
Pyotr Tchaikovsky, tormented by suicidal impulses for
much of his Me, who perhaps best summarized music's
therapeutic properties. "Without music," he once
declared, "I would go insane." ■
experienced the involuntary neuromuscular tics that
would support such a diagnosis.
Others have glimpsed hints of Asperger's syndrome
in his intense focus on music and his struggles with inter-
personal relationships. Mozart was often socially inept,
but anyone making a diagnosis based on his interpersonal
deficits must acknowledge that his operas contain
extraordinary insights into human nature.
Some scholars have speculated that Mozart suffered from
a mood disorder, possibly cyclothymic or bipolar disorder.
They have found evidence of mania in his amazing bursts of
productivity; he composed his magnificent final three
symphonies in six weeks. But he wrote more than 600
compositions in his short Lifetime, and applying this stan-
dard would suggest he had been in a manic phase from
the age of five until his early death thirty years later.
His mood shifts had Httle correlation with his creative
output. He composed melanchohc pieces in spirited moods
and joyful music while despondent. During the last year of
his hfe, when he was suffering enormously from depres-
sion, he produced The Magic Flute, which contains some of
the most enchanting and rapturous music he ever vvrote.
Regardless of whether Mozart would have satisfied
any contemporary criteria for a psychiatric diagnosis, he
clearly experiericed psychological conOict. His father had
exerted tremendous control over him during his child-
hood and seemed reluctant to relinquish that control
when Mozart grew to adulthood. The two waged epic
battles. His father urged him to write popular, more remu-
nerative music, for example, while Mozart desperately
wanted to establish his own artistic voice. Mozart was
torn between the desire to please the father who had nur-
tured his talent and the desire to assert his independence.
The former prodigy, accustomed to receiving fawning
attention from royalty, did have trouble growing up. As a
youngster, he digested obscure textbooks on counter-
point, wrote sophisticated operas, and had to forgo much
of the unstructured play that most children are permit-
ted. As an adult, he was often childish, impetuous, and
tactless. He frittered away his family's money and missed
deadlines on his commissions, behaviors that only wors-
ened after his father's death. But Mozart did make the
transition from wunderkind to mature master, and the
compositions he wrote as an adult have far more subtlety,
depth, and passion than anything he wrote as a child.
The mystery of artistic genius is a fascinating one for
those of us who seek to understand the human mind.
The scorching speed at which Mozart lived — and com-
posed — will continue to fuel speculation on his behav-
ior and the source of his creative intensity ■
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
SCHUMANN WOULD he besieg e d hy delu sional thoughrs
He would have auditory hallucination s as well, cacop Vionmis
sounds he could not dislodge from his hrain
LUDWIG VAN
BEEIHOVEN
1770-1827
THE TALE IS OFTEN TOLD that Ludwig van Beethoven,
upon becoming completely deaf, sawed the legs off
his piano so he could feel its vibrations through the
floorboards as he composed. We can easily imagine
him sitting at that keyboard: unruly hair, wild eyes,
fingers pounding the keys so forcefully that the
strings broke.
Beethoven has long evoked the image of a tortured,
mad genius. He had an intense, tempestuous personal-
ity, and he could slip from rage to raucous laughter to
serenity within minutes. His hearing loss, which
began while he was in his late twenties, became the
central torment of his life. Deafness can be a hardship
for anyone; for a musician, it's a catastrophe.
When Beethoven lost his hearing, he contemplated
suicide. But then he decided to seek salvation in the
music he could no longer hear. With his career as a
virtuoso pianist now ended, he dedicated himself
anew to composing.
Once Beethoven locked himself into the silent
world of his imagination, his musical genius blos-
somed. Unable to hear the music of his contempo-
raries, he conjured a world of sound different from
anything previously conceived. Much of his music
reflected struggle and the attempt to achieve transcen-
dence over that struggle. And his music, with its sudden
shifts and enormous unpredictabihty, mirrored his
emotional volatihty. Beethoven was capable of translat-
ing melancholy and ecstasy into musical terms with
unmatched virtuosity.
One result of this inner unleashing was the Ninth
Symphony, one of his most celebrated works. Poignantly,
during the Vienna premiere of the work, Beethoven,
in his first onstage performance in a dozen years, hov-
ered alongside the conductor, offering tempos to an
orchestra that for him was sUent. Following the sym-
phony's conclusion, the contralto gently turned
Beethoven around so he could witness the audience's
thunderous applause.
In 1812, the collapse of a romance with a woman
known as the Immortal Beloved convinced Beethoven
he would never experience marriage or a convention-
al family hfe. The emotional fallout led to an extended
period in which his productivity dropped precipi-
tously. After his brother's death, he directed his energy
toward the aggressive pursuit of sole custody of his
nine-year-old nephew. He became overtly psychotic
during this custody battle, accusing the boy's mother
of poisoning her husband and insisting against all
evidence that he was the actual biological father of
the child.
After bitter and protracted legal wrangling,
Beethoven was eventually awarded guardianship of the
child. The creative floodgates opened after his \'ictory,
and the glorious final phase of his career commenced.
The rages he had expressed as a younger man softened,
and his music became more spiritual and ethereal than
anything he had previously composed.
Centuries later, the composer still provides one of
the greatest examples of the sublimation of suffering
into the creation of masterpieces. His moods, he
once wrote, "... sound, and roar and storm about me
until I have set them down in notes." Fittingly,
Beethoven died amid the thunderclaps of a savage
spring storm. ■
24
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
ROBERT
SCHUMANN
1810-1856
THE YEAR HE MARRIED Clara Wieck, Robert Schumann
wrote nearly 150 love songs. His staggering productiv-
ity was a sign of his infatuation with the brilliant
young pianist, but it also signaled his entry into the
manic phase of his bipolar disorder.
No composer illustrates the link between mental
illness and creativity better than Schumarm. Analyses
of historical figures are speculative by nature, but his
carefully kept diaries provide detailed information
about his mental state for nearly every day of his
adult life.
In those diaries, Schumann wrote that he believed
that the sole purpose for composing music was to
express the composer's state of mind. While his con-
temporaries were writing music following estabUshed
forms like the sonata, Schumann was revealing ghmpses
into his psychological world through pieces with such
titles as Rapture and Feverish Dreams. And that world
was filled with racing thoughts and flights of ideas.
Schumann composed prolifically during his manic
periods. In one two-week burst of inspiration, he com-
pleted three string quartets, barely pausing for sleep.
Such creative frenzies were inevitably followed by
months of torpor, both literal and musical. During his
depressive periods, Schumann was unable to concen-
trate. He would be besieged by delusional thoughts,
convinced he was worthless as a composer. He would
have auditory hallucinations as well, cacophonous
sounds he could not dislodge from his brain.
Although Schumann felt hounded by these intrusive
sounds, illness brought him undeniable creative advan-
tages. The hypomanic state of his bipolar disorder
brought him increased energy, a decreased need for
sleep, and a sharpened imagination. His racing thoughts
were frequently accompanied by a heightened mental
flexibihty, resulting in innovative ideas and imaginative
solutions to creative problems.
As Schumann grew older and more psychologically
disorganized, he turned to music as a source of heal-
ing. Despite his mistrust of musical form, he began
engaging in the writing of fugues and counterpoint,
compositional techniques that rely on intricate sets of
rules. He discovered that when his tfiinking was espe-
cially chaotic, composing under the constraints of
meticulous guidelines helped organize his thoughts
and sometimes lifted his spirits.
Yet even music ultimately failed to cahn his fevered
thinking. At age 43, Schumarm jumped off a bridge into
the Rhine River, but nearby fishermen thwarted his
suicide attempt. He was taken to a mental asylum,
where he spent the final two and a half years of his life.
His deterioration in the hospital was dramatic. It has
been suggested that neurosyphihs may have exacerbat-
ed his psychiatric disorder, and he was subjected to a
range of ineffective treatments, such as phlebotomy.
A piano was available in the hospital, yet he never used
it; one of the most poignant features of his terminal ill-
ness was his loss of interest in music.
One can only imagine how many more masterpieces
he could have offered the world. Schumann once lament-
ed that he had a hundred symphonies racing through his
mind simultaneously. "Sometimes," he vwote, "I am so
full of music, and so overflowing with melody, that I find
it simply impossible to write down anything." ■
CLARA AND ROBERT SCHUMANN
SPRING 2008 • HARVARD MEDICAL ALUMNI
THE TREMENDOUS E NERGY Gershwin had p mired into
delinq uent hehavior became redirecred . ''Smdyin^
Studying
piano," he said, ''made a good ho y out nf a had one"
PYOTR
TCHAIKOVSKY
1 840-1 893
WHEN CONDUCTING an orchestra, Pyotr Tchaikovsky
would use his right hand to flourish his baton — and
his left hand to keep his head fastened to his neck. He
was convinced, he said, that when he mounted the
podium his head would detach and fly off. This delu-
sion reflects the psychological torment that plagued
the Russian composer during his troubled life.
Tchaikovsky was chronically depressed, and he filled
his diaries with suicidal musings. "I have a boundless feel-
ing of loneliness, despair," he once wrote. "I'm experienc-
ing an insane sorrow Death is really the only blessing."
The composer tried to numb his emotions with alcohol.
"A man tormented by feelings such as mine simply cannot
live without alcohol poison," he confessed to his diary 'Tm
drunk every evening, and I cannot Hve otherwise."
But the only truly effective therapy for his despon-
dency, he found, was composing music. And it was dur-
ing his most intense personal crises that he wrote some
of his greatest music. This pattern of crisis and compo-
sition was set early: His mother died of cholera when he
was just fourteen, and he wrote his first musical compo-
sition within several weeks of her death.
Through his music Tchaikovsky sought to escape his
anxiety and despondency by concocting fantasy worlds.
His classical ballet masterpieces — Swan Lake, Sleeping
Beauty, The Nutcracker — featured whimsical places of
beauty and grace in which he could find solace.
Yet his escapes were fleeting. Fear of being exposed as
a homosexual dominated Tchaikovsky's life. This wasn't
an irrational phobia; in czarist Russia, homosexual acts
were punishable by loss of civil rights and banishment to
Siberia. He spent his entire adulthood obsessed with
hiding what he termed his moral ailment, going so far
as to marry a woman to try to escape social scrutiny.
The disastrous union ended after just six weeks.
When Tchaikovsky died at the peak of his powers at
the age of 53, the official verdict was that he had suc-
cumbed to cholera after drinking tainted water. There
is credible evidence, however, that he had become
involved with a teenaged boy and had committed suicide
to avoid the public humiliation of a sexual scandal.
Tchaikovsky's final symphony, Pathttique, which pre-
miered just days before he died, contains one of the
most haunting evocations of death in all of music. As
tragic as his torment was, it hkely enhanced his music.
We can hear in his compositions intense suffering,
melodic inspiration, and the transformation of great
anguish into great art. ■
I
GEORGE
GERSHWIN
1898-1937
AS A BOY growing up on the Lower East Side of New
York City, George Gershwin misbehaved. He set fires.
He stole from pushcarts. He started fistfights. He played
hooky. When he managed to attend class, he could
barely sit still. Had he been a child today, he might
have been sent to a psychiatrist, diagnosed with conduct
disorder or attention deficit hyperactivity disorder, and
sent home with a prescription for Ritalin.
But Gershwin discovered his own medication at the
age of ten, when he overheard a classmate's violin
recital through an open window. From the moment
the boy played the first notes of Antonin Dvorak's
Humoresque, Gershwin was so entranced he decided
26
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
LEONARD
BERNSTEIN
1918-1990
"I'M THE ONLY PERSON I know," Leonard Bernstein once
declared, "who is paid to have a fit in pubhc." And his per-
formances as conductor validated his statement: He
would flail his arms, wag his brow, and shake his great
mop of hair. Audiences loved him. And he loved audiences.
Bernstein's versatihty was breathtaking. He excelled
as a composer, pianist, and music educator. He rel-
ished the collaborative nature of musical theater, with
the score for West Side Story his best-known contribu-
tion to Broadway. He was most in his element, though,
when conducting a hundred musicians before an
to dedicate his life to music. The tremendous energy he
had poured into delinquent behavior became redirect-
ed. "Studying piano," he said, "made a good boy out
of a bad one."
Gershwin's hyperactivity became a hallmark of his
musical persona; it is hard to imagine that those inces-
sant, rapid-fire notes in Rhapsody in Blue could have
been composed by anyone who wasn't hyperactive. And
as a pianist, his style was fast and clipped. When asked
why he played even slow songs that way, he responded,
"We are living in an age of staccato, not legato."
Sadly, in his mid-thirties, at the peak of his career,
Gershwin lost a great deal of his vitality when he fell
into a depression. Neurological symptoms, such as the
perception of a phantom smell of burnt rubber, soon
joined psychiatric ones. What he didn't know — and
what his doctors wouldn't discover until the day before
his death on an operating table — was that his brain
hod been in the grip of a fatal tumor.
Part of what I find compelling about Gershwin's
decline is that his depressive symptoms coincided with
his creation of Porgy and Bess, an opera that explores
somber and painful themes. Gershwin, until then large-
ly known for a repertoire of buoyant love songs, sud-
denly produced songs of lament and even anguish. As
his illness began to temper his staccato nature, he pro-
duced a work of extraordinary depth and profundity. ■
audience of thousands of people. He was probably the
most sought-after conductor in the world during
his lifetime.
Yet his gifts were shadowed by an internal struggle.
Bernstein longed to write symphonic masterpieces,
and he believed he had the talent to do so. But he had a
hyperthymic temperament: energetic, exuberant, and
indefatigably sociable. He was therefore far better suit-
ed to performing than to the largely solitary task of
composing. Whenever he sat down to write a classical
piece, he felt overwhelmed by the loneliness of
the process. While he did
produce some wonderful
symphonic works, he died
believing he had fallen
short of all that he wished
to achieve.
Some people have sug-
gested that hyperthymic
individuals — with their
high energy and elevated
baseline mood — are the
fortunate few who are
hard-wired for happiness.
But some hyperthymics
can experience a precipi-
tous drop in mood when
they feel stymied. In the
last decade of his life, Bern-
stein suffered episodes of
severe depression, with
each feeding an endless
cycle of hobbled creativity
and renewed despondency.
During those later years,
Bernstein found it demor-
alizing to be celebrated
more as a conductor than as a classical composer, for he
believed only classical composers could achieve
immortality. Ironically, nearly two decades after Bern-
stein's death, professional performances of his popular
compositions occur almost daily around the world.
Each month, dozens of theaters worldwide stage West
Side Story, which premiered more than five decades ago.
And the audiences Bernstein found so necessary still
love his work. ■
Richard Kogan '81, a Juilliard- trained concert pianist and a
Harvard-trained psychiatrist, also co-directs the Human Sexuality
Program at Weill Cornell Medical Center For more information
about the performance-lectures he gives on the internal strug-
gles of composers, visit http://alumnibulletin.med.harvard.edu.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
27
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Rampant violence in his barrio leads a boy to risk his
life to immigrate to the United States — and inspires
him to become a healer, by Harold Fernandez
this side of
MY BROTHER AND I WERE TOLD TO STROLL TWO BLOCKS
south, enter through the main marina gate, and proceed to
the dock, where a boat would be waiting for us. The instruc-
tions were simple enough. But that walk was the scariest of
my life. • No stars illuminated the sky over the tropical island
of Bimini as we stumbled along in the dark; our only light
came from two small lamps at the marina entrance. There we
were startled to see a tall man in a cowboy hat pointing to the
dock. I felt a surge of panic. He wasrit part of the plan. Had
something gone wrong?
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
29
I could feel myself trembling as we continued to the
end of the dock, where another man helped us onto a
boat and guided us to its pitch-dark cabin. We couldn't
make out the faces of the people already huddled there,
and no one spoke. The only sounds we could hear were
the murmurs of the two men on deck, the lapping of
water, and our own labored breathing. Soon the boat's
engine came to life, and we began to move.
It was midnight on October 26, 1978, when my broth-
er and I were smuggled, along with ten other illegal
immigrants, onto a small pleasure boat to cross the
treacherous waters of the Bermuda Triangle. Byron
was eleven; I was thirteen.
Tempting Fate
Danger was not new to me; it had long been woven
into the daily fabric of life in my hometown. I grew up
in Barrio Antioquia, a poor neighborhood of Medellin,
Colombia, with a long and rocky history. In the early
1950s, the mayor had designated Barrio Antioquia the
city's "zone of tolerance," to allow legalized prostitu-
tion. Within days, hundreds of houses were converted
into brothels, with red lights casting an odd glow over
their entrances.
Although the designation lasted only a few years, it
tore at the social and moral fabric of the barrio and left
it vulnerable to exploitation. Decades later, when the
city became home to the Medellin Cartel, one of the
world's most powerful drug-trafficking organizations.
Barrio Antioquia served as a key suppHer of young tal-
ent; the leaders; the sicarios, or hired assassins; and the
mulas, or drug couriers. To retain their power and
gain prestige, many cartel members formed gangs; Barrio
Antioquia alone had eight.
Under the leadership of the notorious Pablo Escobar,
known as El Patron, or The Boss, the cartel grew to be
almost as powerful as the official government of the
country. Escobar was popular with the poor because
he made considerable donations to charitable organi-
zations, established welfare programs, and built hous-
ing complexes, soccer stadiums, and churches. At the
same time, the city remained hostage to his reign
of brutality.
Medellin and its people suffered deep wounds from
the cartel's horrific acts of violence. During the worst
30
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
(p/eimMili
people witnessed the fight, but no
one ventured close to help the dying teen. An hour elapsed
before an ambulance arrived to pick up his body.
years, the city had a homicide rate more than five times
those of the most violent cities in the United States.
Despite this, the cartel held an allure for young peo-
ple living in the despair of a poverty so deep that even
toilet paper was considered a luxury. In contrast, the
cocaine industry promised enormous wealth and
power almost overnight. I remember spending hours
with my friends gazing covetously at the flashy cars
and motorcycles the drug traffickers parked outside
neighborhood bars. The temptation proved too great
for some of my friends; without exception, those who
joined the drug trade ended up either imprisoned or
gunned down.
PI
aying i
n Traffi
ic
As a boy, I spent most of my free time playing soccer in
the streets of Barrio Antioquia. Many of my friends
played in bare feet because they couldn't afford shoes;
on weekdays they eagerly waited for me to finish my
homework, as I was the only one who owned a ball.
Although this material poverty was difficult, it was
the spiritual poverty — the loss of childhood inno-
cence — imposed by the drug trade that was far harder to
bear. It even invaded our childhood sports. One hot sum-
mer day I was sitting by the side of my house, watching
a soccer game, when an older player, Alvaro, started
arguing with Marlon, a player from the opposing team.
They began pushing each other, and Alvaro knocked
Marlon to the ground. Marlon jumped up, rammed
Alvaro with his head, and ran off. The game continued.
A half hour later, I suddenly heard a gunshot. I could
see Alvaro, just ten feet from where I sat, clutching his
side, trying to stanch the blood now soaking his shirt.
Then I noticed Marlon sauntering off, a gun dangling
from his hand. He neither ran nor made any attempt to
hide his weapon.
Alvaro was bundled into a car and rushed to the
emergency room. He was fortunate; the bullet had
missed his major organs, and he was released from the
hospital a week later. No one pressed charges because no
one had the courage to testify against Marlon. He was
not only a member of a powerful gang, but also a sxcar'w
for the cartel. Just fifteen years old, he had already killed
several people in the barrio.
A few months later, from behind the curtains of a win-
dow, I witnessed Marlon's death. He had been staggering
down the street, drunk and high on drugs, when he ran
into a member of a rival gang. The argument that ensued
quickly escalated into a scuffle. Marlon didn't have a gun
this time; instead, he puUed out a machete. His opponent
had no weapon, but he was older, taller, and neither
drunk nor high. He picked up a rock and pounded
Marlon's head until he knocked him to the ground.
There he savagely punched and kicked him. Within
minutes, Marlon lay motionless in a pool of blood.
Several people witnessed the fight, but no one ven-
tured close to help the dying teen. An hour elapsed
before an ambulance arrived to pick up his body.
Again, no one was charged, and the crime was never
officially solved.
Islands in the Stream
For every Colombian who became involved in drug traf-
ficking in those years, thousands more fled to fields and
factories in the United States, seeking peace, security,
freedom, and economic opportunity. My parents, who
were already living in New Jersey as undocumented
workers, were growing increasingly desperate to
remove my brother and me from the barrio. They made
arrangements, and we received elaborate instructions.
Our adventure started with what was supposed to
look hke a routine departure from the Medellin airport.
We needed to keep a low profile; only a few people could
accompany us to the airport, and we had to behave as
though we were leaving for just a vacation, not a lifetime.
Yet my entire extended family showed up, along with
many friends. My grandmothers and aunts were sob-
bing, and I was terrified about what the officials watch-
ing us might be thinking.
As Byron and I crossed the tarmac toward our plane,
I glimpsed the terrace where I had stood to wave good-
bye to my father four years earher and to my mother two
years after that. Now I was on the other side, waving to
a crowd of well-wishers. At best I would not see my
beloved grandmothers for a long time; at worst I would
never see them again.
The group we were traveling with stopped in Panama
briefly before boarding a plane to the Bahamas. During
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN 31
^/w aw^Mt-eoAe
scenano was
no lorn
[er
the layover, customs officials detained one member of our
group; we never saw him again.
According to the plan, we would stay in Bimini for less
than a day. After arriving at our hotel, more than a dozen
of us met to finalize our plans. Our boat trip would take
place at night to reduce our odds of being caught by
the U.S. Coast Guard. We were now only 50 miles from
Florida, and the voyage would last five to six hours. I was
excited; one day more, and I would see my parents.
The leader of the group collected our fees — about $600
apiece — and instructed us to wait while he met with our
local contact. When the leader returned, though, he
brought bad news. The sea was too rough. Even more
worrisome was that our contact didn't know when we
could leave. Hurricane season was in full force. Our
departure would depend on the weather.
For the next twelve nights, after our hghts — and that
day's hopes — ^were extinguished, we would hear tapping
on our door and unfamiliar voices offering us boat rides to
Florida. We had been instructed to answer that we were
merely on vacation and had no interest in crossing to the
United States. As the days passed, and the members of our
group grew more anxious, several accepted those offers.
We never learned whether they made it safely to Florida.
Those of us remaining had been warned that Bimini
was swarming with undercover immigration officers
looking for people who were trying to cross to the Unit-
ed States. To avoid drawing attention to ourselves, we
pretended to be tourists. But by the end of the first week,
our tourist visas had expired. We holed up indoors; if
caught, we could be deported.
Finally the weather broke. That night we would risk
death for a chance to live in the United States.
The Young Man and the Sea
As we huddled in the dark cabin of the boat, the reahty of
our situation hit me hard. I dreaded crossing the Bermu-
da Triangle, infamous for the mysterious disappearances
of so many planes and ships. Byron and I couldn't swim
and had no life vests. The worst-case scenario was no
longer getting caught by the U.S. Coast Guard and being
sent back to Colombia; it was dying at sea.
The movement of the boat soon became unbearable.
We felt the constant cycle of a steep chmb, a sudden
descent, and a bang so loud it made us shriek in terror. At
the end of each cycle it felt as though the boat would spht
in half. We all began praying aloud.
We also began throvvdng up. After a while, we didn't
even try to maintain decorum. We vomited everywhere.
Most of us sat with our heads down, praying, retching, and
chnging to someone or something to avoid being thrown
across the floor. On deck, the captain was fighting to main-
tain control of the vessel, while the sole crew member used
a bucket to try to bail out the water sloshing into the boat.
Hours passed. Finally, on the other side of the cabin's
small door, darkness began to give way to hght. With the
dawn, the waves grew milder. The rocking motion of the
boat eased and the thump of the boat against the waves
softened. We aU began to feel safer.
After hours of throwing up we were so dehydrated
we could barely rise from a sitting position. Yet as we
approached the Florida coast, the boat slowed, and I
managed to stand up and peer through a cabin window.
In the distance I could see other boats and a shoreline
with buildings. I realized we were in U.S. waters.
For an hour the captain searched for a safe place to
dock. Meanwhile, those of us in the cabin cleaned our-
selves up as best we could and chmbed up on deck. It was
a beautiful, sunny day. The boat stopped at what
appeared to be an abandoned dock. As we stepped off the
boat, the captain handed us cards showing our location.
It felt wonderful to stand on land again.
My brother and I found a pubhc telephone several
hundred yards away and called my parents' friends to let
them know we had arrived. They put us up for the night,
and the next day they drove us to the Miami airport,
where we boarded a flight to Newark.
The Dreaming Spires
Our first summer in New Jersey proved pivotal. Byron
and I had behaved during the school year, enduring the
taunts of classmates, who often called us refugees, and
struggling to learn Enghsh, a language we had barely even
heard before. But now with the summer months we
savored our freedom. From the streets of MedeUin we had
brought not only advanced soccer skills but some bad
habits as well. We smoked; we drank; we threw empty
bottles at storefronts.
My parents despaired that they had waited too long to
briag us to the United States. Yet they also understood
that this was a critical time in our development. So when-
ever we visited my father at work, he would take time to
show us his working conditions. He spent twelve to four-
teen hours a day in a dank, dark building with no air con-
ditioning and the deafening sound of embroidery
machines. He cautioned us that if we didn't take advan-
tage of the opportunities this country offered, we would
end up working under similarly bleak conditions.
32
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
getting caught by the U.S. Coast Guard; it was dying at sea.
FAMILY CIRCLE: Clockwise
from far left: the author
as a student in Medellin;
as a baby ^th his par-
ents in Cali, Colombia;
and as a five-year-old
standing with his brother
Byron. Upon reuniting
with their parents after
a harrowing sea crossing
to the United States in
1978, Harold and Byron
met a U.S.-born brother,
Marlon, then sixteen
months old, for the first
time. A fourth son, Alex,
was born in New Jersey
three years later.
These conversations with my father proved effective. In
the eighth grade I buckled down and became a model stu-
dent. My success through high school grew so much that
I soon had my sights on Princeton, a university I had come
to admire while competing in track meets on its campus.
But as the time to apply to college drew near, I needed
a green card and a Social Security number. I wasn't eligi-
ble for legal residency, so I bought a green card on the
black market. With that document, I could apply for a
Social Security card. But when I went to a local office of
the U.S. Immigration and Naturalization Service, the
clerk, after taking my documents, excused herself to
make a phone call. I panicked. I grabbed my papers, fled
the building, and ended up purchasing a fake Social Secu-
rity card instead.
My family had long Hved in a shadow society, ever fear-
ful of discovery, ever conscious of dodging immigration
authorities. After I enrolled at Princeton, I felt like an
imposter as I gazed at the imposing gothic architecture
that F. Scott Fitzgerald had so eloquently described in his
debut novel. This Side of Paradise: "... topping all," he wrote,
"climbing with clear blue aspiration [were] the great
dreaming spires of Holder and Cleveland towers."
Like Fitzgerald's protagonist, I loved Princeton from
the beginning. But as I walked through campus I doubt-
ed my right to be there. For starters, I was an illegal alien;
I had used a phony green card and Social Security number
in my apphcation. I also harbored serious doubts about
my scholastic achievements, and I suspected my SAT
scores were the lowest of anyone in my class. My accent
mortified me. Whenever I spoke, I thought the other stu-
dents must be wondering how anyone with such a heavy
accent could possibly have been accepted.
One evening, at the beginning of my second semester
at Princeton, I received a letter from the dean of my col-
lege. She wrote that my first-semester grades had placed
me at the top of my class. She congratulated me and
encouraged me to keep up the good work. With that
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
33
^9^ tAe (pk}/enee that ensued,
hundreds of people across the city — including police
officers, judges, and politicians — were murdered.
letter, I began to relax. Perhaps I had earned the right to
be part of this historic institution after all.
The Legal Limit-
Just weeks later, that sense of belonging vanished when I
found a second letter waiting in my student box, this
time from the dean for foreign students. As I opened it, I
assumed it would be an invitation to a social event. But
instead I discovered an official missive asking me to bring
in my original legal residency documents so they could be
photocopied and included in my file.
Suddenly I felt sick. Years before, during my ocean
crossing, the fear of discovery had compounded my feel-
ing of seasickness. Now the fear of discovery rose again,
along with my nausea. I realized how vulnerable I was;
the wonderful dream that had begun at an abandoned
boat dock on the Florida coast was about to end.
After agonizing for several days, I realized I had two
choices. I could present the dean for foreign students
with my forged documents. But I decided this wouldn't
work; I didn't have the stomach to continue my charade.
My second option was to meet with her and admit I didn't
have any legal documents. First, though, I decided to
share my problem with someone I trusted.
So one afternoon, after class, I asked my Spanish ffter-
ature professor, Arcadio Diaz-Quinones, for a few min-
utes of his time. He replied that I could have as much time
as I wanted. He closed the door and sat down with me at
a table. I tried to speak, but instead, under his sympa-
thetic gaze, I burst into tears. He put his hand on my
shoulder as I wept with my head on the table. After sev-
eral minutes, I Mted my head and managed to talk. I
detailed for Diaz all I had done to enter this country and
conceal my residency status. I told him about my fear of
being expelled or even deported.
Diaz listened patiently to my story. When I finished,
he advised me not to tell anyone else. Over the next few
weeks, he met with several administrators. At first, he
discussed the problem with them in theoretical terms,
without mentioning my name. He then set up a meeting
with university officials. They decided that I should
meet with the dean of my college, the same woman who
had sent me the encouraging letter at the start of my
second semester.
Nancy Weiss was just as friendly in person as she had
seemed in her letter. She told me that Princeton was proud
to have me in its student body. But the university had two
problems with my case. First, I had broken its honor code.
Second, I had been receiving U.S. government grants.
Since I wasn't a legal resident, this was against the rules.
But then Weiss went on to tell me that both problems
had solutions. For the first one, I needed to write a
detailed essay explaining my understanding of the honor
code, how I had broken it, and why I was seeking a par-
don from the university. To resolve the second problem,
the university would change my status from that of a
local student to that of a foreign student. With this
change, Princeton could provide all my grants and schol-
arships with university funds.
I left the office feeling great rehef ; I could square with
Princeton. But this was far from the end of my troubles.
Now that my undocumented status — and that of some
family members — had been revealed, we had to move
quickly. While the university was willing to let me stay,
immigration authorities could opt to send my family
members and me back to Colombia.
Princeton arranged for us to meet with one of New
York's top immigration lawyers, who confirmed what we
already knew: My family didn't qualify for any of the cat-
egories under which people already in the country could
be granted legal residency. We needed a miracle.
As it turned out, our first meeting with an immigra-
tion judge was a success. We weren't granted legal resi-
dency, but we weren't deported, either. Instead, we were
entered into a category known as suspension of deporta-
tion proceedings, meaning that although we didn't qual-
ify for any of the immigration proxisions, the judge was
sympathetic. He realized that my family was humble,
honest, and hard working.
Our case seemed as if it would drag on forever, and
over the next several months I spent many hours reading
my organic chemistry textbook while standing in line at
the regional immigration office in Newark. But in August
1986 the judge announced that he was ready to decide our
fate. We dressed in our best clothes and filed into the
back of the courtroom, waiting for our case to be called.
When the judge dehvered his verdict, my parents, who
understood only Spanish, didn't immediately grasp his
meaning: He had granted us legal residency.
34
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
You Can't Go Home Again
As a boy living with my grandmothers in Colombia, I
often witnessed our doctor making house calls. The doc-
tor would come to our house, examine my grandmothers,
and provide healing advice over a cup of coffee. I also
noticed that physicians, who could support their famihes
without resorting to unlawful activities, were revered in
the barrio. I wasrit the only one paying attention; from
the time I was young, my grandmothers had decided I
should be a physician. They even scrimped to buy me a
toy doctor's kit.
By the time I applied to medical school, I had confi-
dence in my ability to achieve my professional dream. I
was a legal resident and had done well at Princeton.
When I received a letter of acceptance to the Harvard-
Massachusetts Institute of Technology program in
Health Sciences and Technology, I happily accepted.
It was during my time at Harvard Medical School
that I returned to Medellin for a research project. In the
summer of 1992, with an education grant from Brigham
and Women's Hospital, I undertook an evaluation of
the city's emergency medical care system. My goal was
to observe how critically injured patients were treated
in the trauma center of the city's main public hospital,
San Vicente de Paul. I analyzed ambulance response
times, transportation modes to the hospital, and the
care provided.
One of my findings was that trauma victims
tended not to be transported by ambulance. The
injured, especially the victims of gunshot and
knife wounds, were usually taken to the hospital
by friends or family members in private cars. This
finding didn't surprise me; I had only to recall
what happened when Alvaro had been shot on
that summer's day so long ago.
During the six weeks of my study, I stayed at
an aunt's house in Barrio Antioquia. This was the
time when violence in Medellin — and my old
barrio in particular — had reached its peak. Pablo
Escobar had recently turned himself in to the
Colombian government to avoid being extradited
to the United States. In exchange, he was allowed
to build his own luxurious jail. La Catedral, on
a mountaintop overlooking Medellin. His con-
finement was widely regarded as a joke — and
an embarrassment to the government. He was
rumored to be overseeing the cartel from his
prison and to be coming and going as he pleased.
But Escobar's hold on the city was no joke.
One evening, I was sitting on the balcony of my
aunt's house when the calm was shattered by the
sound of gunshots. As I peered over the edge of
the balcony, I witnessed the cold-blooded killing
of a young man just a hundred yards away. The
killer coolly walked away with the gun in his
hand. The victim's family rushed him to San Vicente de
Paul, where he was declared dead on arrival. Before my
eyes he had become one of the more than 150 homicide
victims in my old barrio that year.
A week before my return to Boston, Escobar escaped
from custody, and his organization started a ruthless
campaign of terror against the government and the
innocent people of Medellin. In the violence that ensued,
hundreds of people across the city — including police
officers, judges, and politicians — ^were murdered.
On my return fhght, I thought about how dramatical-
ly my life had changed since that night in the dark cabin
of a sea-tossed boat. If I had stayed, I wondered, would I
have become one of the doctors working in the emer-
gency department at San Vicente de Paul, or would I have
been recruited into a short life of drug trafficking and
violence? Would I have fallen victim to an unsolved mur-
der, just as seven members of my extended family had?
Now, in my work as a surgeon, I often remember the
senseless slaughter of aU those young men and women.
The helplessness and fear I felt when witnessing violence
have since given way to the confidence and knowledge
that my education and experiences as a healer have
instilled. My grandmothers were right; I have found
much satisfaction in a life that helps relieve suffering. ■
Harold Fcrncmdcz '93 is a cardiothoracic surgeon at St. Francis
Hospital in Roslyn, New York.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
35
ta Medicine needs to steer a course that
batancis inspiration and science to achieve
a health care system that works for al ..
NINE YEARS AGO the television program IsHgktlinc
spent a week at Harvard Medical School filming our
approach to patient care. The reporter took ample time
with our students and faculty, and the program devel-
oped a wonderful picture of our high standards of care
and our emphasis on the doctor-patient relationship.
At the end of that week, the reporter and I were wafk-
ing together when he suddenly asked, "What happens
if you train your students the way you've shown me
hy Daniel D. Federman
36 HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
|, -«,». ssy^JS^
»mmam
s many as 50 million are uninsured, half that number mm
class are just a serious illness away from bankruptcy
and they then enter a world that worit let them practice
as they were taught?" Without a moment's hesitation, I
answered, "Then they ought to change the world."
A medical student's life should be intellectually daz-
zling, emotionally rewarding, and morally transcendent.
It should be intellectually dazzling because the progress
in biomedical science — from genomics to imaging to
molecular diagnosis to therapy — gives the process of
becoming a doctor incandescence. It should be emotion-
ally gratifying because the opportunities for helping
individual patients and populations of patients achieve
better lives have never more closely aligned with enter-
ing students' aspirations. And it should be morally tran-
scendent because from the first day of medical school
one should feel enhsted in the never-ending challenge of
achieving better health for aU.
Yet several imbalances persist in medical education
today, while our health care system as a whole is sailing
off course. Among these educational imbalances is the
one between inspiration and science. At first glance this
notion may seem both plulistine and counterintuitive. I
don't mean medical schools have too much science; their
faculty members in basic science represent a major frac-
tion of the country's biomedical scientists. These teachers
dehght in sharing their research passions with medical
students. And since the introduction of evidence-based
thinking in clinical departments, that domain of medical
education has become rich in science.
My point, rather, is that medical education offers too
httle inspiration. Medical students don't spend enough
time with the senior faculty who are eager to nurture
their talents. They don't witness the continuity of
patient care that is the essence of internal medicine.
They don't see surgical patients before the patients are
draped — that magical moment in which one human
gives another human permission to cut into his body.
And they spend too much time with junior faculty and
with residents who are often too tired, irritable, and
troubled to inspire young people.
Even Keel
It's a long way from the bench to the examining table.
Most of the scientists in our basic science departments
hold doctorates but have no training and often httle
interest in medicine. And in recent years, faculty
members have been rewarded for basic science
research through appointments, promotions, honors,
and opportunities for supplemental income. Important
advances in basic science are now crying out for clinical
investigation and translational research, and we're des-
perately short of people entering those disciplines. We
must rebalance the value structure of our schools to
invite bright young students into translational research.
In addition, we need teacher-clinicians who remain
close to the emerging science of their areas — even
though they are not doing the research — and can convey
the meaning of this progress to medical students and
patients alike. These individuals are critical members of
medical school faculties and should be developed and
rewarded as such. Outstanding examples of the role of
teacher-chnician have been grossly underrepresented in
the past, and that balance should be restored.
A close coroUary of this imbalance is an inadequate
respect for clinical excellence. Most medical students
will practice medicine, and their learning environment
and experience should include a veneration of outstand-
ing doctoring with all it entails.
There is no such thing as too much attention to the
indi\ddual when one is caring for the sick. All one's intel-
lect and empathy must conjoin in the ser\'ice of diagnosis,
management, and care. But in the overall distribution of a
medical student's time, we pay too much attention to
what is immediately wrong and give too httle thought to
preventive measures addressing what is likely wrong or
what is going to be. The closer you hover to death, the bet-
ter a fourth-year medical student or intern can serve you.
Yet most people are not at any given time fatally ill, and
the almost onanistic absorption v/ith the chnicopatho-
logical conference, our most revered teaching function,
should be replaced with a broader interest in likelihoods,
prevention, and ameUoration. This emphasis should be
enriched with insights from social science, including a
focus on the patient's family and the pubhc as a whole.
By a wide margin, though, the most serious imbalance
in the education of our students is the faculty's focus on
the intense care of the sick while the setting in which
that care occurs — the U.S. health care system — is in seri-
ous disarray and getting worse. As many as 50 milhon
are uninsured, half that number again are underinsured,
and many members of the middle class are just a serious
iUness away from bankruptcy. In addition, gross dispar-
ities of care and health indices persist along racial,
ethnic, and socioeconomic lines. We fail to apply the
38
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
power of preventive measures well enough to make a
difference, and our health outcomes are barely competi-
tive with those in developing countries.
Where is the disquiet that African American new-
borns have more than twice the mortality of whites?
Where is the outrage that more than half our citizens
cannot access or afford routine primary care? Where is
the shame that among 19 industriaUzed nations we are
ranked dead last in health care measures? Where is
the horror these findings should evoke? And where is the
agreement, or at least the debate, that health care is a
fundamental right, one no more ahenable than those
protected in the U.S. Constitution?
Sailing Close to the Wind
To help answer such questions, perhaps we should
start by analyzing the clinical exam. Imagine for a
moment watching a doctor-patient encounter as
though you were utterly naive of it. First, two
strangers meet in a closed room, unobserved. One is
fully dressed, the other at least partially undressed.
Within a minute or two — especially these days — one
of them starts asking questions not only about medical
symptoms, but also about intensely private matters,
such as sexual preference, the number of sexual part-
ners, and the consumption of any illicit drugs. And the
other person answers if not with aplomb then certain-
ly with the view that the questions — which would
have absolutely no standing in any other setting — are
appropriate in that room.
Next, the questioner moves on to a physical examina-
tion that combines intrusiveness and physical access
completely without parallel in social interaction. With-
out consent, the process of the physical examination
would indeed fit an expanded definition of rape.
Third, the person in the flimsy hospital gov\Ti agrees to
take medications the fully dressed individual suggests —
up to and including general anesthesia. In other words,
there is a total submission, admittedly with informed
consent, to an undoing of consciousness and self.
And finally, the questioner receives permission to
operate on the other person — to remove an organ, to
perform a transplant, to alter the body in any way he or
she deems fit. This final act, which takes place every
day in our operating rooms, would be a felony in any
other setting.
40 HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
s it ethical to have patients wandering in the
decide whether to pay for food or a new prescription?
what justifies this extraordinary transaction? A sim-
ple utterance, "Good morning! I'm Dr. Jones." And with
those words comes the unspoken but unqualified
promise that the person has the knowledge, skills,
and — most important — the commitment to use them
ethically on the other's behalf.
But is it ethical to have appointments so short that you
can't remove the shoes and socks of a diabetic patient? Is
it ethical to have an elderly patient with poor vision on
a dozen drugs when you have no access to a database of
drug interactions? Is it ethical to have patients wander-
ing in the doughnut hole of Medicare Part D and needing
to decide whether to pay for food or a new prescription?
Clear Sailing
Such imbalances bring me to a metaphor from the
world of sailing. There are three principal points of sail.
When the wind is at your back, the boat is flat and
progress is real but almost imperceptible. There's no
tipping so there's no problem with balance. When
there's a following sea, however, you can feel a little
sick to your stomach.
When you're sailing on a reach, or perpendicular to
the wind, the boat is still almost flat and your lunch can
remain stable. The sandwiches won't slide, the wine
won't slosh. Again, balance is no problem. But sailing
across the wind will not get you to a challenging target.
When you want to go exactly where the wind is coming
from, you can't. You have to slant shghtly off the direct
course, which is called beating, or sailing to windward.
Now the boat is heeling, and maintaining balance can
be difficult.
But when things go exactly right — the sails are
trimmed perfectly, the crew's weight is distributed
correctly, and the sheets are as tight as possible — the
thrill is incomparable and you can let out a scream. It's
not truly human; it's not even primate. But it's close to
a primal scream, and it signals that the boat is sailing as
well as it can against the wind, and progress toward
the goal is predictable.
I stated earher that the worst imbalance in current
medical education is the failure of our medical schools to
trumpet the defects of the U.S. health care system and to
commit to correcting them. Our health care system has
terrible shortcomings. I beheve we should erdist medical
students as agents of change, committed to designing a
system of care that is equitable, cost-effective, preven-
tion oriented, and universal — and thus moral. The stu-
dents should have coursework, summer experiences,
projects, an activist focus, and consistent mentoring on
this subject. I envision a program similar to an MD/PhD
or other joint-degree design. I picture a cadre of dedicat-
ed and innovative faculty who would bring to the pro-
gram insight from diverse areas of medicine and from the
social sciences. Following this rich activist experience
should be additional medical training that prepares
these students for leadership.
I don't know what the specific recommendations
would be. (Peter Medawar, the British immunology
Nobelist, said, "Never ask me about the future of
research. If I knew what it was, I'd be doing it now") But
I'm not troubled that we'll be starting with amateurs.
Noah's ark was built by amateurs; professionals built the
Titanic. Similarly, I'm not concerned that we'll be starting
with so few people arrayed against the titans of health
care. As Margaret Mead said, "Never doubt that a small
group of thoughtful, committed citizens can change the
world. Indeed, it's the only thing that ever has."
If we can convince medical students and faculty to
apply the standards of medical education to the prob-
lems of health care; if they search for solutions that are
intellectually dazzling, emotionally gratifying, and
morally transcendent; if they join with students and fac-
ulties from related disciplines in pubhc health, social sci-
ence, and economics; and if they recognize that a broad
systems approach is needed, then we'll see roaring
progress to windward.
There's a big wind out there opposing change. It is
generated by a hugely successful commercial and for-
profit world entrenched against the radical revision of
health care that I believe we need. But when our new
craft is saihng just right — when the hehn, the sails, the
sheets, the keel, and the crew are all in balance — and we
start to make our ineluctable course to windward,
through the noise we'll hear that deep, throaty, primal
scream, and we'll know we're on the way to better health
and health care for aU Americans. ■
Daniel D. Federman '53, the Carl W. Walter Distinguished Professor
of Medicine at Harvard Medical School, has served as a mentor
to generations of EMS students. This article was adapted from a
tribute Federman gave to Jordan Cohen '60, president emeritus of
the Association of American Medical Colleges.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
41
HEALTH CARE CRISIS
SOLITARY WEIGHT: A 15-year-old
schoolgirl, burdened by AIDS,
av/aifs antiretroviral treatment'
at a clinic in South Africa. The
care came too late; she died
two weeks after this photograph
v/as taken.
^"^IW
^
I'
itigp
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Jk
f in
HffifT^
M
*«-
ml
^HI^^B^^^kLmJ
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THE OBSTACLE
OURCE
The most critiCciJ roadblock to'
(:kli\ Cling care in tfu: lu \Li(ip.mg
\\(ir1d i^ 110! money, hut an
!nip1emcntati( . bottleneck.
hy Jim Yonc; Kim
EACH YEAR AT LEAST TEN iVlILLION
preventable deaths occur around the world.
Most of these deaths take place in develop
ing countries, usually among children,
young mothers, and people with HIV. While
more money is alwa)"s needed, funding isn't
the biggest challenge we face in preventing
these tragedies The biggest challenge is the
delivery gap that prevents existing, often
simple health interventions from reliably
reaching those who need them.
The situation in Africa is especially dire.
In southern Africa, millions have already
died from xAIDS. In South Africa, more than
one -quarter of adults are infected with the
virus. The HIV epidemic has also created a
resurgence of tuberculosis, which kills more
than a million people a year. Again, the toll
SPRING 2008 • HARVARD MEDICAL ALUMNI BUUETIN 43
espite the existence of proven treatments and much mc^rc
money available now to pay for them, an implementation
30ttleneck prevents care from reaching patients.
is highest in Africa. A child dies of malaria every 30
seconds, and most of those deaths occur in Africa as
well. Every year, v^e bear vs/itness to millions of deaths,
all from conditions that are routinely treated in the
developed world.
Meanwhile, health spending in Africa — both pub'
lie and private — though much improved over the past
decade, falls far below levels found almost anywhere
else. The number of physicians working in Africa is
just as skewed. We often hear that more Malawian
physicians live in Manchester, England, than in
Malawi, and that more Ethiopian doctors can be
found in Chicago than in Ethiopia.
What's especially tragic is that we know how to
prevent or treat the most prevalent and deadly dis-
eases. Take, for example, the risk of an HIV-positive
mother transmitting the virus to her unborn child.
Currently, the best way to prevent transmission is
to provide the mother with prenatal services and, if
appropriate, a combination of antiretroviral therapies
to reduce viral load to undetectable levels. In an emer-
gency, a single dose of nevirapine wUl also prevent
transmission. Yet only an estimated 30 percent of
pregnant women who need prevention-of-mother-to-
chUd-transmission services actually receive them. And
only half of pregnant women infected with HIV have
access to nevirapine.
Statistics on the use of insecticide-treated bed nets
to prevent malaria infection are just as troubling. These
nets can reduce infant mortaUty from malaria by 20 to
30 percent. Every African child Hving in areas where
disease-carrying mosquitoes are endemic should be
sleeping under a bed net, but less than 10 percent do.
In neither of these cases is the problem the lack of a
proven solution. The fundamental problem is one of
consistently and effectively delivering interventions
that are known to save lives.
Bridging the Gap
African nations and other resource-poor countries are
not alone in this delivery gap, of course. The U.S.
health care system has its own share of delivery
problems. As of several years ago, we were still only
69 percent successful at meeting the standard for
administering beta blockers within 24 hours to people
admitted to hospitals for chest pain. The United
States spends up to 17 percent of its gross domestic
product on health care, and yet our health outcomes
aren't as good as those in countries that spend far less.
Admittedly, few African countries can rely solely on
their own national budgets to fund the kind of health
care systems they need. But the estimated cost of pro-
viding decent primary care — and even more comph-
cated care — in developing countries is much lower
than one might expect. A recent analysis of a project in
Rwanda suggests that it is possible to build a system
that — when linked to primary care services — can
treat such diseases as AIDS, tuberculosis, and malaria
for $25 to $50 per person each year. Compare that to
the United States, where we spend about $7,500 per
person on health care annually.
As funding for health in developing countries
grows, it is conceivable that there will soon be
enough resources to build functioning health care
systems in even the poorest settings. To achieve such
a lofty aim, though, we will need to dramatically
improve our capacity to deliver health care interven-
tions, both simple and complex, in resource-poor set-
tings. Eor, despite the existence of proven treatments
and much more money available now to pay for them,
an implementation bottleneck prevents care from
reaching patients.
Meanwhile, the Bill & Melinda Gates Foundation
and other funders are investing billions of dollars to
develop new tools to treat the deadliest diseases. This
investment is absolutely critical. Any physician who
has confronted drug-resistant tuberculosis will tell
you how desperate the need is for new treatments.
But when these new tools hit the market, I fear the
bottleneck will just become more clogged.
One key to clearing the bottleneck is, I believe, to
work toward developing what might be called the
science of health care delivery — to systematically
capture global health successes and failures, study
them, and then widely disseminate the lessons
learned to practitioners and policy makers. More-
over, we must create robust programs that will train
a new generation of implementers and link those
implementers together in communities of practice
to allow the process of generating — and spreading —
new insights to continue.
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
FEVERED PURSUIT: This year-old boy v/aits 'with his aunt for malaria treatment at a hospital in Tanzania. Unless treated
within 24 hours of developing symptoms of the disease, children under the age of five risk death.
The Discovery Channel
At the press conference to announce the eradication of
smallpox in 1979, physician and epidemiologist D. A.
Henderson was asked, "Now that you've eradicated
smallpox, what's the next major disease you want to take
on?" His answer: "Bad management in pubhc health."
Indeed, if you asked anyone who was involved in
smallpox eradication what it was Kke to be part of a vac-
cination campaign of that magnitude, they would tell
you it wasn't a vaccination campaign. It was an epidemi-
ological and management campaign — and those strate-
gies were the key to the campaign's success. That kind of
intense focus on management and implementation is
lacking in today's efforts to stamp out other diseases,
which just might help explain why we're falling short.
Health care delivery is complex, but it's not a black
box. We can and must develop better ways to capture
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
45
c \'c made hiipc contrihurions to clinical research
the science ot health care
> ( \t^\A\j(^r\i
HOME ALONE: Orphans hold candles of remembrance
during a ceremony marking World AIDS Day in
Johannesburg, South Africa. More than one-quarter
of adults in South Africa are infected >vith HIV.
this complexity and then teach what we learn about
effective care delivery to our students here and — most
important — in the developing world. We can lay claim
to being the best in the world at teaching basic sci-
ence. We've made huge contributions to clinical
research and clinical science. But one piece is miss-
ing — the science of health care delivery. To overcome
the challenges we face today in global health, we need
a new cadre of leaders — ones who are trained in the
best and most effective ways to dehver interventions.
Of course we need to keep investing in health care
systems in poor countries. We need better infrastruc-
ture; we need more money for medications, equip-
ment, and supplies; we need new therapies. All of
these things are critical, but this type of investment
won't unstop the implementation bottleneck.
In fact, if we don't unclog the bottleneck, we run
the risk that much of what we invest will be wasted.
Today, we have literally billions of dollars in new
spending — all of it sorely needed — to treat disease in
the developing world. But we don't have support — or
even a plan — for the creation of leaders who will
ensure the money is well spent.
Stopping needless deaths in the developing
world — from AIDS, from tuberculosis, from malaria —
is within our reach. Let me tell you about a recent
patient of ours in Rwanda. Jean presented at our clin-
ic with both tuberculosis and HIV. He hterally looked
hke a skeleton. Yet his CD4 count was over 500, so we
didn't need to start him on antiretrovirals. With just
food and medications for his tuberculosis, he began to
recover. In a short time, he had his health back and,
soon, had grown downright chubby.
This case illustrates what is possible, not just for
Jean, but for nulUons of others. The challenge and the
opportunity are before us — to significantly increase
our understanding of effective care dehvery, to teach
what we learn to implementers worldwide, and to
make good on the promise of dramatically improving
the health of poor nations. ■
]im Yong Kim '86 is chairman of Harvard Medical Schooh
Department of Global Health and Social Medicine, director of
the FrangoiS'Xavier Bagnoud Center for Health and Human
Rights at the Harvard School of Public Health, and chief of the
Division of Global Health Eciuity at Brigham and Womens
Hospital. This article was adapted from the HMS Alumni Day
Symposium talk he gave in 2007.
46
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
Change of Address
Harvard Medical School is playing a new role to help
ensure the sustainability of international health projects.
Despite unprecedented new financial
resources and medical advances, a
significant global health delivery gap
prevents care from consistently reach-
ing the patients who need it most. To
remedy the situation, Jim Yong Kim
'86, chairman of Harvard Medical
School's Department of Global Health
and Social Medicine, teamed with
Paul Farmer '90, a cofounder with Kim
of Partners In Health, and Michael
Porter, a Harvard Business School pro-
fessor who leads in the field of strate-
gy for complex organizations, to
launch the Global Health Delivery Pro-
ject (GHD). Their goal: to transform
global health delivery from a series of
small, well-intentioned but disconnect-
ed efforts to a worldwide movement
based on twenty-first-century technolo-
gy, standards, and efficiency.
Effective and consistent care delivery
is, in many ways, a managerial chal-
lenge: In poor settings especially, its suc-
cess depends on understanding the mul-
tiple factors that affect complex health
systems, as well as the ability to carry
out basic public health functions, accom-
modate multiple medical specialties, and
mobilize staff, facilities, and information
over sustained periods. Yet efforts to
capture and learn from program experi-
ences have been limited, leaving global
health implementers isolated, with little
opportunity to learn from colleagues'
experiences or to share their own.
GHD aims to create such opportuni-
ties by — for the first time — systematically
evaluating the outcomes of care deliv-
ery projects worldwide and sharing
them with other global health imple-
menters. To jumpstart this initiative,
GHD is developing a new generation
of tools that not only use rigorous
analysis, but also draw on numerous
disciplines, web-based information-
sharing communities, and partnerships
with centers of excellence in health
care delivery.
In doing so, GHD has taken a les-
son from Harvard Business School by
creating analytic frameworks, include
ing in-depth field case studies that doc-
ument the best and most challenging
examples of health care implementa-
tion. Ten such case studies have been
completed, with 25 more planned for
the next two years.
The project's online presence,
GHDonjine, is just as critical. The web^
site's virtual communities of practice
connect health care implementers
across borders. By joining the commu-
nities, implementers throughout the
world can rapidly share their best
practices and experiences, collaborate
with peers both locally and internation-
ally, and access an extensive library of
practical information. And a targeted
custom search engine allows members
to quickly find relevant information
without weeding through standard
search results. The first four GHDonline
communities to become active now
center on tuberculosis infection control,
patient adherence and retention, drug-
resistant tuberculosis, and health infor-
mation technology.
But current health care implementers
aren't the only focus of GHD. A new
academic field of global health delivery
studies will teach tomorrow's global
health leaders to become experts in
health care implementation. A curriculum
is being developed to reach a range of
students — including undergraduates,
graduate students, physicians, and mid-
career global health implementers — in
the United States and around the
world. Using GHD's in-depth global
health case studies, this new curriculum
is being piloted at Harvard before
being made widely available.
GHD plans to partner with a num-
ber of centers of excellence to create
hubs for collaborations that link acade-
mic institutions, nongovernmental orga-
nizations, and public sector health care
delivery organizations. Such partner-
ships will allow faculty to study care
delivery at leading global health sites
and to teach their findings to students.
These training sites will also offer pro-
gramming as diverse as field intern-
ships for graduate students, sessions for
large groups of community health work-
ers, and executive education leader-
ship courses for mid-career profession-
als. GHD expects to establish three
partnerships with centers of excellence
during the next five years.
To learn more about the Global
Health Delivery Project, visit www.
globalhealthdelivery.org. ■
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN
47
hy John W. Gittinger, Jr.
^m^
INSIDE
BONES BROUGHT THEM TOGETHER,
the surgeon and the dentist-physician —
bones and the nearly magical light that
penetrated flesh to reveal them. That magic
was the x-ray. During the latter half of the
1890s, both men would use this newfound
hght in ways that would prove pivotal to
future generations.
The surgeon rode the wave of early
enthusiasm for the technology to construct
a Christmas card that boasted an x-ray of
his professor's arm — and the Civil War
bullet lodged in it for nearly three decades.
48
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
Early investigations of <y\>
x-ray by two Harvard- ^
educated physicians ^
revealed the technology's '7
benefits — and dangers. ^
He also used the technology to lay a founda-
tion of anatomical knowledge that would for-
ever inform his profession.
The dentist-physician, a man for whom
research was a part of life, devoted decades
to characterizing the new imaging tool and to
tweaking its design to improve its perfor-
mance. He also sought to make the technology
safer: An x-ray-induced injury to his hand
proceed with care.
We don't know if the two men ever met.
They did, however, debate one another in the
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN 49
-LvL-yl A ALy O stated, "X-light kills" He then presented
evidence by detailing the fatal results that two-hour exposures on each
of eleven days had produced on two robust male guinea pigs.
pages of the Boston Medical and Surgical Journal.
The exchange between these two — Ernest
Amory Codman, Class of 1895, and Wilham
Herbert Rolhns, Class of 1879 (and Har-
vard School of Dental Medicine Class of
1873) — ^was brief but feisty. It occurred
in 1901, less than five years after a holi-
day card and an injury had affected each
maris life.
Take a Letter
It was in the winter of that year when letters
exchanged between Rollins and Codman
appeared in the weekly predecessor to the
New England Journal of Medicine. The corre-
spondence began with a note from Rollins,
published on February 14, a day usually
reserved for hearts and flowers. For Rollins,
however, it was a day for directness and
urgency: "X-hght Mis," he began.
Rollins then presented evidence of the dan-
gers of x-hght — a term he persisted in using
when describing the x-ray — by detaihng the
fatal results that two-hour exposures on each
of eleven days had produced on two robust
male guinea pigs. Rollins was convinced his
experimental design showed x-rays were the
deadly force. The experiment was hardly
RoUins's first or last with these energetic
waves. It would become one of near-
ly 180 investigations, observa-
tions, and comments he
united in his book
Notes on X-Light,
pubhshed in 1904
by The Univer-
sity Press in
Cambridge,
Massachusetts. The findings he was reporting
to readers of this medical journal had been
introduced three years earher in an engineer-
ing journal. Rollins elected to restate them for
physicians; without proper precautions, he
worried, x-rays posed significant dangers to
both patients and doctors.
At least one reader took an interest in
Rollins's letter. With a rapidity not found in
printed journals today, the February 21 issue
of the journal carried a response from Cod-
man. In "No Practical Danger from the X-Ray,"
Codman stated, with the occasional added
emphasis, ''practically, in careful hands, there
is no danger from the use of the x-ray to the
patient and very httle to the operator." He went
on to describe thousands of exposures he had
made of patients at Massachusetts General
Hospital, Childreris Hospital, and in his pri-
vate practice, "without a single case of der-
matitis," an outcome that stepped carefully
around Rollins's worry that cumulative and
unprotected use caused death, albeit death to
a laboratory animal. To ensure Rollins under-
stood the breadth of his experience in the
field, Codman signed himself, "Surgeon to
Out Patients, Massachusetts General Hospital;
Skiagrapher [an early term for radiologist] to
the Childreris Hospital."
The journal's next issue contained Rollins's
response. In it he provided a second example,
this time involving a pregnant guinea pig. The
fetal guinea pig had died, a lesson Rollins
extrapolated to humans, cautioning that he
was aware of one instance where the use of
x-rays had caused a woman to abort. Empirical
to his core, Rollins then gently upbraided his
critic. With new agents, he said, it was impor-
tant to determine their power so as to know
how they could be controlled. "Nothing is
gained by criticizing such experiments,"
Rollins wrote, "for criticism is sterile, while
CODMAN
X-'Ray" that, ymctically, in careful hands, there is no danger from the use
of the x-ray to the patient and very httle to the operator." _^^__._ . _
experiment is fertile. An experiment can only
be discredited by another experiment."
Catch Some Rays
So who were these correspondents, and what
was their interest in this new tool that could
see to the bone? Rollins, age 48 at the time, is
considered the Father of Health Physics. He
was also the first to describe radiation-induced
cataract. Codman, who had just turned 31, is
celebrated as both the Father of Shoulder
Surgery and as the founder of the End Result
System, the outcomes movement that gave
birth to today's Joint Commission on Accred-
itation of Healthcare Organizations.
Like many physicians in the late 1800s,
Rollins and Codman were drawn by the
promise and mystery of the wondrous hght
that had been introduced to the world by a
quiet German physics professor. In November
1895, Wifhelm Rontgen had been experiment-
ing with cathode ray tubes when he made one
of those experimental mistakes that history
christens serendipitous. During a test, Rontgen
placed a cardboard screen that had been
treated with a fluorescent substance, barium
platinocyanide, in front of an electrified vacu-
um tube known as a Hittorf-Crookes tube.
hi the darkened laboratory, the tube pro-
duced fluorescence on the cardboard screen.
Satisfied with the test, Rontgen was about to
turn off the tube when he glimpsed a Hght sev-
eral feet from where he was working. To see
what it was, he struck a match. Its glow fell
upon a forgotten screen that had been coated
vvdth a fluorescing solution and left to rest on
his workbench. His surprise turned to amaze-
ment when he realized the screen was being
illuminated by a faint cloud of fhckering Hght
waves that moved in unison with the electrical
discharges of the tube's inner coil.
Rontgen began feverishly testing the
properties of the phenomenon. A month later
chance again intervened, and one of the
principal future uses of the ghostly glow was
revealed. As Rontgen was placing an iron pipe
between an electrified Crookes tube and
a capture screen, he saw the bones of his fin-
gers as they grasped the pipe.
Rontgen quickly wrote up his findings for
pubhcation. They were immediately accepted
and Rontgen's paper, accompanied by an
x-ray of his wife's ring-bearing hand, was
circulated among a select group of German
physicists. By the end of January 1896, "On
a New Kind of Rays" had been translated
into Enghsh and published in a London-
based engineering journal. Soon it was the
talk of scientists and physicians on both
sides of the Atlantic, and by year's end, an
incredible 1,044 papers on x-rays had been
pubhshed in medical and scientific jour-
nals. In 1901 the discovery earned Rontgen
the first Nobel Prize in Physics.
Ray of Hope
Following Rontgen's announcement, hos-
pitals throughout the world quickly opened
x-ray rooms. By May 1896, Boston City Hos-
pital had set up an x-ray department, over-
seen by the physician and early radiologist
Francis Williams, Class of 1877. Williams's
fascination with x-rays was matched —
perhaps surpassed — by that of his collabora-
tor, Rollins, who also happened to be
Williams's brother-in-law. For nearly
two decades, the two men took
x-rays of hospital patients,
amassing more
\
BOWDITCH,„„™ofa
Dullet lodged near his elbow since his military service,
x^^as delighted when an x-ray revealed the Ci\il War relic.
150,000 images as well as an understanding of the tech-
nology that Rollins would use in his efforts to refine it.
In his writings, WiUiams credits his brother-in-law
with being one of the first to recognize the treatment
potential the technology offered medicine. But perhaps
each inspired the other. In the preface to his Notes on
X'Light, Rolhns attributes his dedication to the field to
Wilhams: "In these notes are recorded some impressions
derived from experiments made after the day's work, as a
recreation, yet with the hope of learning to design and
construct apparatus for my friend. Dr. F. H. WUhams,
who has done most to show the importance of X- Lights
in medical diagnosis." This "recreation" was both kind
and costly. Although RoUins had a thriving dental practice
in Boston, his passion for research and invention contin-
uaUy challenged the household income. In the last volume
of his personal journal, Rollins credits the mindfulness
and thrift of his wffe, Miriam, with the fact that his
research, which may have cost upwards of $30,000 over
the years, strained, but never broke, the RoUins's bank.
Rolhns continually chronicled his observations and
experiments in his Notes. By early 1898, he had begun
jotting down reports of what would become just one of
the dangers of the technology: skin burns, a problem he
had learned of on the job. In January of that year, RoUins
suffered a severe burn on one of his hands after it was
exposed to an activated vacuum tube.
For the next six years, Rollins devoted himseff to
determining the dangers of x-rays, devising precau-
tions to protect against those dangers, and redesigning
the vacuum tubes and apparatuses associated with the
technology to improve the efficiency of the tubes and
the resolution of the radiographic images. Some of his
inventions — the Rollins box, a shielded housing that
permitted rays to escape only through a single opening;
the use of coUimating diaphragms to narrow the beam;
and the development of high-voltage tubes — ultimate-
ly served to limit the exposure of patients, physicians,
and other workers who operated or produced x-ray
equipment. In addition to hardware improvement,
Rollins dispensed cautionary advice to those who
applied the technology to medical purposes: wear
radio-opaque glasses; enclose the tube in a leaded
housing; and limit irradiation of patients to only those
areas of interest, covering adjacent areas with radio-
opaque material.
Unfortunately, RoUins's cautions were ignored, per-
haps because of the bhnd enthusiasm of those working
with the new technology. Or perhaps the neglect
occurred because Rollins toUed alone in his home labo-
ratory, pubhshed his findings quietly and in somewhat
obscure engineering journals, and rarely ventured to
professional meetings. His reluctance to participate in
such meetings was so great that he had to be persuaded
to attend an American Roentgen Ray Society gathering
at which he was awarded an honorary membership. The
citation he received may have only added to Rolhns's
frustration; it did not mention his x-ray safety work.
Brought to Light
As with Wilhams and Rollins, Codman was mesmer-
ized by the x-ray and its ghostly images. In 1895 Codman
had just begun his surgical practice and his position as
an assistant in anatomy at Harvard Medical School
when he began exploring Rontgeris rays. Like many
who were probing the new technology, Codman sought
out the needed equipment. The proper ingredients were
found right in the laboratory of his mentor, Henry
Pickering Bowditch, Class of 1868.
Codmaris excitement is palpable in his writings of this
period. In the autobiographical preface to The Shoulder, a
landmark treatise published in 1934, Codman wrote: "It
would be impossible to give the reader an idea of the thriU
experienced by those of us who did the early X-ray work.
1 remember that an early contribution of mine in the Boston
Medical and Surgical Journal was to show that the X-ray was
likely to help us in studying the epiphyseal lines! . . . We
almost forgot that it was all because Rontgen had noticed
something that many others might have obsers'ed."
For two of his years in Bowditch's laboratory, Codman
concentrated on taking images of the entire human
skeleton, a body of work he gathered into a single bound
edition that he donated in 1898 to the Rare Books Room
at the School's Francis A. Countway Library of Medi-
cine, where it stiff resides.
Codman also may have indirectly used the x-ray as a
courtship tool. In his first year of work with Bowditch,
Codman took an x-ray of the professor's right arm. The
image dehghted Bowditch, for it clearly showed a rifle
buffet lodged near his elbow, a rehc he had been unaware
of for 30 years but had likely acquired during his ser^'ice
52
HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2008
in the Civil War. Codman, too, was pleased by the image,
so much so that he turned it into a Christmas card for the
professor. The careful surgeon and researcher made a
mistake on the card, however. "Merry Christmas" became
"Marry Christmas," perhaps an inadvertent shp revealing
Codmaris affections for the professor's niece, Katherine
Putnam Bowditch. The two were married in 1899.
Codman continued to research the apphcations of
x-ray for several more years, giving special attention to
its uses in the practice of surgery. Before long, though,
the pull of surgery won Codman over and he set aside
x-ray work. As his autobiographical preface shows, this
return to surgery may also have allowed him to express
his change of heart about the dangers of x-ray exposure:
"for we all had burns and some of us gave them. Many of
my old friends are dead from x-ray cancer. It was fortu-
nate for me that my interest in surgery was greater than
in Rontgen's discovery."
Indeed, evidence of the dangers of unprotected
exposure to x-rays was mounting. Radiologists offered
the best — or worst — proof. Their ranks were being
thinned by early deaths. And those who lived had the
evidence written in their hands: scarred, distorted, and
often lacking digits. Such disfigurement was so preva-
lent that banquet planners for radiology meetings in
the 1920s avoided serving roast beef; the gloves most
radiologists wore to hide their hands made cutting
such food dffficult.
Service for Two
Before he died of metastatic cutaneous melanoma in 1940,
Codman had built a considerable legacy. His "End Result
Idea" or "End Result System of Hospital Organization"
would lead to the estabhshment of standards for the mea-
surement of the outcomes of medical care. And in addi-
tion to his contributions to the field of surgery, Codman
had developed the Registry of Bone Sarcomas. Spurred by
the development of a bone tumor in "one of my best
patients," Codman had contacted physicians throughout
Massachusetts, poUed them on their bone sarcoma cases,
and compiled the treatments and outcomes they had
achieved. After a book on bone sarcoma and five years of
work — done without compensation — Codmaris data
engendered the first cancer registry in the United States.
Rollins, too, left a legacy, one that mandated discov-
ery in generations to follow. In addition to his research
and inventions in radiology — as well as in dentistry,
photography, radio, and mechanical pianos and
organs — Rollins sought to ensure there would
always be an opportunity to tinker and dream. In
his wlH, he bequeathed $58,000 to the Smithsonian
Institution for the establishment of a fund "for
exploration beyond the boundaries of knowl-
edge." The fund was formalized in 1935, six years
after his death.
Rolhns's warnings of the dangers of x-rays lay
quietly through decades that brought war and mass
destruction until those of a new age, the atomic era,
rediscovered — and began to heed — them.
Absent a record of a meetimg or even of other
letters personally exchanged between these physi-
cian-researchers, it is impossible to know if they
ever had the chance to discuss face-to-face the dif-
ference of opinion they had inked for pubhc airing.
It is tempting, however, to think they did. After
all, both were members of Boston's professional
class and had affiUations, either direct or indirect,
with Boston's social register. Both were avid out-
doorsmen, each arranging their professional
schedules to include blocks of days out of the city
on hunting and hiking getaways. And both
enjoyed walking along the streets of the city's
Back Bay neighborhood, where they li\'ed just a
few blocks apart.
Had they talked, they hkely would have discov-
ered that aside from this single professional dust-
up, they approached hfe with much the same \dsion.
They would have found that each held as a core
value the importance of a life devoted to humanity. ■
]ohn W. Gittingcr,]r. 71 is a professor of ophthalmology and
neurology at Boston University School of Medicine.
SPRING 2008 • HARVARD MEDICAL ALUMNI BULLETIN 53
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